mobile informatics - health management

THE OFFICIAL VOICE

OF THE EUROPEAN

IMAGING INITIATIVE

VO L U M E 6 IS S U E 5 NO V E M B E R - DE C E M B E R 2006

I S S N = 1377-7629

Latest Advancesin 3D Imaging

Medical Imaging in Germany

MIR 2006Congress Review

Guide to Staf fManagement

M O B I L E I N F O R M AT I C SI N R A D I O L O G Y :TRANSFORMING WORKFLOW

M O B I L E I N F O R M AT I C SI N R A D I O L O G Y :TRANSFORMING WORKFLOW

www.imagingmanagement.org

RADIOLOGY ■ CARDIOLOGY ■ INTERVENTION ■ SURGERY ■ IT MANAGEMENT ■ EUROPE ■ ECONOMY ■ TRENDS ■ TECHNOLOGY

EDITOR-IN-CHIEF

Prof. Iain McCall (UK)

EDITORIAL BOARD

Prof. Hans Blickman (The Netherlands)

Prof. Georg Bongartz (Switzerland)

Prof. Nevra Elmas (Turkey)

Prof. Guy Frija (France)

Prof. Paolo Inchingolo (Italy)

Prof. Lars Lonn (Sweden)

Prof. Heinz U. Lemke (Germany)

Prof. Jarl A. Jakobsen (Norway)

Prof. Mieczyslaw Pasowicz (Poland)

Prof. Udo Sechtem (Germany)

Prof. Rainer Seibel (Germany)

Dr Nicola H. Strickland (UK)

Prof. Henrik S. Thomsen (Denmark)

Prof. Vlastimil Valek (Czech Republic)

Prof Berthold Wein (Germany)

CORRESPONDENTS

Prof. Frank Boudghene (France)

Prof. Davide Caramella (Italy)

Nicole Denjoy (France)

Johan De Sutter (Belgium)

Prof. Adam Mester (Hungary)

Sergei Nazarenko (Estonia)

Dr. Hanna Pohjonen (Finland)

GUEST AUTHORS

David Bandon

Matthew Barish

Liz Beckmann

Jim R. Brown

Hans-Peter Bursig

Harry Granito

Henrik Echternach Gregersen

Gordon Harris

Peter Mildenberger

Eric Poiseau

Osman Ratib

Maximilian Reiser

Jarmo Reponen

Antoine RossetMY OPINION

Interview with Prof. E. Poiseau on the aims of Integrating the Healthcare Enterprise (IHE)

COUNTRY FOCUS: GERMANY39 Dr H. P. Bursig

>> The Medical Imaging Industry in Germany

41 Prof. M. Reiser>> German Radiological Society

42 Dr P. Mildenberger>> IT and Workflow Organisation

43 Prof. Dr B. B. Wein>> Education and Training for Radiology

Conference AgendaUpcoming seminars in Europe and beyond

48

26 Dr J. R. Brown>> Beyond the Heart: The Evolving Ultrasound Market

28 Prof. M. Barish, Prof. G. Harris>> Practical Guidelines for a Successful 3D Imaging Service

33 Dr H. Pohjonen, Prof. H. Blickman>> Building Trust in Remote Reporting: Ensuring a Viable Service

FEATURES This issue’s features include:

COVER STORY: MOBILE INFORMATICS IN RADIOLOGY

16 Dr J. Reponen>> Mobile Image Delivery and Acquisition: New Ways to Manage and Access Information

18 Dr H. Gregersen >> The Digital North Denmark Project

19 L. Beckmann >> Enabling Access to Patient Data: Ensuring True Mobility in Imaging

20 Prof. N. Elmas>> Mobile Life in the Radiology Department: Benefits of Mobile Technology

21 Prof. O. Ratib, Dr D. Bandon, Dr A. Rosset>> Wireless Access to Patient Records in a Clinical Environment

HOW TO...

How To… Manage Employees in a Radiology DepartmentPart one of a two-part series exploring employee management strategies in radiology departments, by H. Granito

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EditorialBy Editor-in-Chief Prof. Iain McCall

Association NewsHighlights from the MIR 2006 Congress

EU NewsInsight into the workings of the Committees of the Regions, by Ilze Raath

Industry NewsCoverage of corporate news and updates

Letters to the EditorYour thoughts and feedback

C o n t e n t

The European Imaging Initiative (EII) is

an informal network of related associa-

tions, professionals and leading

European stakeholders concerned with

good management practices in the

imaging industry.

ECRI Healthcare Product Comparison ChartPACS – New product information on Picture Archiving and Communications Systems

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45 47

E d i t o r i a l

I M AG I NG M A N A G E M E N T: T H E O F F I C I A L VO I C E O F T H E E U R O P E A N I M A G I N G I N I T I AT I V E 3

Mobile Imaging Informatics:

Transforming Workflow

E d i t o r i a l

Many healthcare facilities are committing anot inconsiderable amount of human, tech-nical and financial resources, to the installa-tion and implementation of mobile imaginginformatics, providing remote access toexam reports, patient files and images thatcan be used to speed up reporting, queriesand second opinions on diagnoses, as wellas to improve access to research and teach-ing files.

Due to the radical changes brought about bythese technologies, radiological imagesfrom modalities including CT, MR and digitalradiography, can be sent to one centralimage acquisition and storage device. Thesame images can then be circulatedbetween different workstations, patientsuites, handheld PDAs and the internet, viamobile links.

With these transformations, radiologydepartments have the potential to gain con-siderable benefits. The implementation ofmobile technology also has the possibilityto free radiologists from their stationary

computer terminals and workstations andallow them greater contact with patients,clinicians and other involved professionals.These developments must not, however,reduce the standard and quality of radiolog-ical care and must be implemented in asecure way for the benefit of the patient.

In this edition, our cover story focuses onthe many areas of workflow that can be sup-ported by integration of mobile informatics.We address not only the limitations of thiskind of technology, but also the significantbenefits. While the ultimate mobile tool forradiologists may not exist, there are manyoptions that will aid radiologists to providefaster and more timely healthcare.

We welcome your thoughts and feedback.Email your comments to: [email protected].

Prof. Iain McCall

PROF. IAIN MCCALL

EDITOR-IN-CHIEF

[email protected]

HAVE YOUR SAY !

Letters to the editor at [email protected]

More and more, radiologists are realising through gatherings likethe recent ‘Management in Radiology’ congress (Budapest, Hungary,October 5 – 7 2006), that they risk the erosion of their profession asan entity if they fail to recognise the importance of good management practices to improve healthcaredelivery. As well as many invaluable practical management insights from the wide range of presenta-tions that took place, this was the main subject of discussion on the opening day: where will radiologybe in ten years time? The conclusions drawn at the congress were disturbing and thought-provoking.

Prof. Iain McCall: Opening Address“The annual Management in Radiology congress has provenvery successful – international support has played a key role,and we welcome the many colleagues visiting from Americaand Australia. Initially set up by the late Prof. Ernest Mako, asuperb radiologist who sadly died last year, we must offer sin-cere thanks to Prof. Palko and Prof. Mester from the LocalOrganising Committee for picking up the baton. Some of themain management challenges in radiology are rising globalisa-tion with the advent of teleradiology, etc. as well as privatisa-tion of healthcare services in the UK which brings growingchallenges. MIR allows us to explore these to analyse patternsof healthcare delivery.”

The End of Radiology as an Independent SpecialtyOne of the highlights of this year’s congress was a provocativeand very timely debate on the future of the radiologist.Opened by Dr Strickland, who argues against the future needfor today’s traditional general radiologist, with a move frommodality-based focus to sub-specialist organ-based systems,she emphasised that this must be reflected in revised educa-tional structures. Her vision for the future of the radiologist

4 P R O M OT I N G T E A M W O R K A C R O S S D I F F E R E N T D I S C I P L I N E S

sees multidisciplinary meetings as loci where highly spe-cialised radiologists make up part of a clinical team, whichreflects a global knowledge of the whole clinical pathway.

Managing Imaging of the Future This brought many further questions: How much general radiolo-gy education does a subspecialist need? Should there be fast-track specialist education for those who have made their choiceearly on? Is there any need for a general radiologist at all? DrStrickland recommends the medical profession to implementimportant changes to education – ideally after the two generalfoundation years, post qualification as a doctor (already imple-mented in the UK), junior doctors choose an organ system whichthey specialise in for five years. One of the subspecialty disci-plines within each organ system will match that of the imager.The advantages are streamlined patient service, reduced waitinglists, highly specialised equipment and expertise. Dr Stricklandacknowledges that this shift may come with costs: a sub-special-ist imager may miss a diagnosis related to a different organ sys-tem that a general radiologist would not – and it also brings theloss of radiology as a cohesive discipline. Nevertheless, sheargues that the benefits for the majority of patients will far out-weigh the occasional missed diagnosis. Dr Strickland predicts this

A s s o c i a t i o n N e w sAssociat ion News

Highlights ofMIR 2006 CongressManagement Issues Crucial to Radiology

Prof. Iain McCall: Opening Address

inevitable shift will happen in the next ten years, in which radi-ology as a profession will become fragmented into subspecialistimagers making up part of a clinical organ/body system spe-cialised team.

Fighting Fragmentation of the ProfessionProf. Philip Gishen, in contrast,objects strongly to the ‘givingaway of the profession of radiol-ogy’. States Gishen, ‘In the caseof the UK, radiologists tradition-ally tend to be on a fixed salary,thus there is not such pressureon them to perform in compari-son to radiologists operating ona payment by unit or payment by report system. This has theeffect of removing the urgency with regards to protecting therole of the radiologist, who is paid the same whether some ofthe roles and responsibilities are moved to other specialists,e.g. passing reporting to the radiographers. Clearly the gener-al radiologist still has a very valuable role to play, for examplespotting mistakes and having a wider understanding of thepatient’s case history’.

A quick count of raised hands by Prof. McCall revealed that fewin the audience believed the profession of radiology will stillbe integrated in the next ten years. The consensus was thatthe profession will evolve into a more specialised service. Thisraises the important questions: Will clinicians end up doingtheir own imaging? Should radiologists get more involved in

primary care, dealing with the patient as a clinician or dis-tanced as a service provider? As Prof. Andras Palko says, ‘Welive in interesting times’.

Future Congresses and WorkshopsAs of 2007, the administrative organisation of the annual MIRcongress is being transferred to the central ESR office inVienna under the guidance of Peter Baierl. Henrik Silber willorganise the next meeting under new incoming MIR Chair, Dr.Nicola Strickland. Next year’s MIR congress will take place inOxford, UK, 10 – 13 October 2007, and will no doubt attracteven more exciting debate and exchange of knowledge.

As part of its efforts to raise awareness of management issues,MIR is organising its annual workshop on ‘The Art ofLeadership’ to take place in January 3 – 6 2007, in Gstaad,Switzerland. This course, which will be led by coaches TonyPoots (Director, Global Integration, UK) and Gerhard Pohl (GPTraining and Coaching), will cover such issues as:

• Prioritisation• Managing time• Coping with stress• Saying no• Work/life balance



Prof. Paolo Pavone, Dr. Nicola Strickland

Prof. Philip Gishen

Prof. G. P. Krestin, Prof. Iain McCall

F i n d o u t m o r e !

Photos from the congress can be viewed at

www.imagingmanagement.org. Our next edition includes a cover

story highlighting the top presentations from the congress.


IHE Expansion Continues withNew Domains Arising There are four new integration profiles in

trial implementation in the radiology

domain in 2006:

1. Nuclear Medicine Image Integration

Profile (NMI) with Cardiac Option is a

change to the NM Image Profile, improv-

ing functionality for nuclear medicine

cardiac image viewing.

2. Image Fusion (FUS) Integration Profile

specifies communications between sys-

tems, creating and registering image

sets and systems displaying fused

images.

3. Import Reconciliation Workflow (IRWF)

Integration Profile specifies how data

importers obtain local demographics,

coerce patient and procedure attribute

values in the imported data and report

progress/status of the importation

process.

4. Mammography Image (MAMMO)

Integration Profile specifies how DICOM

Mammography images and evidence

objects are created, exchanged and

used. It describes how Acquisition

Modalities transfer Full Field Digital

Mammography (FFDM) images, how CAD

systems act as Evidence Creators, and

how Image Displays should retrieve and

make use of images and CAD results.

From the IT infrastructure domain, there

are two integration profiles which are

particularly interesting to an imaging

manager:

1. Cross-enterprise Document Media

Interchange (XDM): provides document

interchange using a common file and

directory structure over several standard

media. This allows the patient to use

physical media to carry medical docu-

ments. This also enables healthcare

providers to use person-to-person email

to convey medical documents.

2. Cross-enterprise Document Reliable

Interchange (XDR): focuses on providing

a standards-based specification for man-

aging the interchange of documents that

healthcare enterprises have decided to

explicitly exchange using a reliable

point-to-point network communication.

It is a natural complement to the IHE ITI

XDS Integration Profile (for cross-enter-

prise document sharing) when a sharing

infrastructure (repositories and registry)

is not needed.

These new integration profiles will be

tested during the European Connect-a-

thon next Spring. During the last few

months, IHE-Europe has defined a new

governance model, which will reinforce

its involvement in the development of

new profiles, beyond its key role in lab-

oratory and pathology. Based on a close

cooperation with COCIR IT and INRIA, it

will also consolidate the credibility of

IHE, recently referred to in the European

Commission report "Connected Health,

Quality and Safety for European

Citizens”.

IHE Europe is also proud to announce

the election of its new user co-chair

Karima Bourquard. Karima Bourquard

who is with the GMSIH and is also act-

ing as IHE-F user co-chair, succeeds Prof.

Berthold Wein of Aachen. Peter

Kuenecke, Siemens is now fully in

charge of the vendor co-chair position.

The position was shared with Emmanuel

Cordonnier of Etiam over the last year.

IHE- Europe is grateful to Berthold Wein

and Emmanuel Cordonnier for all the

time and energy they spent in promoting

the initiative in Europe and defending

European interests in the technical com-

mittees.

www.ihe-europe.org


healthcare professionals from more than30 countries around the world attendedover a hundred scientific lectures.Abstracts and proceedings are nowonline on the EuroPACS website.

Highlights from the scientific programmeincluded:

• PACS implementation & development in US

• Why do I need medical imaging? • The future of radiology • PACS in Europe –a platform and

tool for integrated solutions• Web-based PACS for all users • Regional eHealth experience and

concepts in Austria• Sharing IT and human resources to

create a multicentre radiology department

• Diagnostic imaging Electronic HealthRecord (EHR)

• Medical images and the future of medicine

www.europacs.org

The EuroPACS conference isone of the largest gather-

ings of specialists in medical imagingand digital systems for eHealth. Thisyear’s edition, which took place inTrondheim, Norway, offered informationon the latest and most significant devel-opments in clinical practice, researchand education within digital radiology.Physicians, radiologists, scientists and

Highlights from EuroPACS 2006

abstracts is January 10, 2007. Topics willinclude the following:

• Medical Imaging• Computer Assisted Cardiovascular

Imaging• Image Processing and Display• Medical Workstations• Image Guided Radiation Therapy• Security, Legal and Ethical Aspects• Clinical Applications and Evaluation• Integrating the Healthcare

Enterprise (IHE)• Telemedicine

Joint Congress ofCAR/ISCAS/CAD/CMI/EuroPACSComputer Assisted Radiology andSurgery (CARS) have announced that the 21st International Congress andExhibition will be held in Berlin,Germany, on the 27 – 30 June 2007.The deadline for the submission of

• Expert Systems and Computer Assisted Education

• Economic and Management Issues• IMAC in Surgery, Pathology, Ophthal

mology, Internal Medicine, etc.• Inter- and Intra-hospital IMAC• IMAC Healthcare Infrastructures for

In-home Care

Further information is available on theCARS homepage.

www.cars-int.org

therefore can be used by personnel atall levels at any time.

The system provides a complete resourcefor managing equipment inventory infor-mation, work orders, service contracts,spare parts, purchasing and stock con-trol in a secure, comprehensive package.

ECRI-AIMS has been specifically devel-oped to meet the needs of Europeanhealthcare by ECRI, in partnership withPhoenix Data Systems Inc. In addition tothe main system components, there aremore than ten optional modules avail-able. With the optional EasyNet PlusTM,

equipment users can raise and progressrequests for service and also viewequipment lists and history informationvia a web browser.

Among the additional modules currentlyavailable are:

• Parts & Purchasing• Service Contract Management• Performance & Quality• Advanced Preventive Maintenance• PDA• Resource Management

www.ecri.org.uk

ECRI-AIMS EquipmentManagement SystemECRI-AIMS has announced a new systemfor managing all aspects of technology-based assets found in European andinternational healthcare institutions. It isa web-browser application, enablingdata stored centrally by the hospital tobe accessed via a web browser connect-ed to the hospital intranet. There is noclient software to install and ECRI-AIMS


Members of the CORThe COR is made up of 317 membersand 317 alternate members, repre-senting local and regional govern-ment from the 25 Member States, asspecified by the Maastricht Treaty.Consequently, members represent thewhole sphere of sub-member stategovernment throughout Europe,including regions, provinces, coun-ties, municipalities and districts. Themembers and alternate members areappointed for four years by theCouncil, acting unanimously on pro-posals from the respective MemberStates.

Responsibilities of the CORIn 2001, the Treaty of Nice strength-ened its democratic legitimacy byintroducing the necessity for politicalresponsibility of its members in theircapacity as representatives of region-al and local authorities. The COR wasestablished to address two mainissues. Firstly, seeing that three-quar-ters of EU legislation is implementedat local or regional level, it wouldmake sense for local and regionalrepresentatives to have a say in thedevelopment of new EU laws.

see important regional or local impli-cations to a proposal. The COR canalso draw up an opinion on its owninitiative, which enables it to putissues on the EU agenda.

Organisation and StructureThe constituent bodies of the Com-mittee of the Regions are as follows:

Plenary AssemblyThe Committee meets as a PlenaryAssembly and its main tasks are:adopting opinions, reports and reso-lutions, draft estimates of expendi-ture and revenue of the Committeeand the political programme of theCommittee; electing all the membersof the Bureau; setting up commis-sions; and adopting and revising theRules of Procedure of the Committee.

PresidencyThe President directs the work of theCommittee. The Committee elects thePresident from among the membersfor a two-year term.

BureauThe Plenary Assembly elects theBureau for two years. It consists of

Secondly, there were concerns thatthe public was being left behind asthe EU was busy expanding andincreasing its power. By involving theelected level of government closest tothe citizens, the gap was being closed.

The Treaties (Nice and Maastricht)oblige the Commission and Council toconsult the COR whenever new propos-als are made in areas that have reper-cussions at regional or local level.The Treaties set out the followingareas:

• Economic and social cohesion• Trans-European infrastructure

networks• Health• Education • Culture• Employment policy• Social policy• Environment• Vocational training• Transport

The Commission, Council andEuropean Parliament have the optionto consult the COR on issues not cov-ered by the above-mentioned if they

COMMITTEE OF THE REGIONS

ILZE RAATH

EDITOR EUROPEAN AFFAIRS

[email protected]

The Committee of the Regions (COR) was created by the MaastrichtTreaty in 1992 and provides a forum for local and regional authoritieson issues affecting them. It is an advisory body that ensures publicauthorities are consulted on EU proposals of direct interest to them,especially as they are often responsible for implementing these poli-cies. Its work is organised through six commissions that examine thedetails of proposals and then draw up a draft opinion, which high-lights where there is agreement with the European Commission's pro-posals, and where changes are needed.

EU News

Key Role of the COR


the President, the first Vice-President,one Vice-President per Member State,25 other members and the chairmenof the political groups (56 membersin total). The Bureau is responsiblefor implementing the COR's politicalprogramme.

CommissionsAt the beginning of each four-yearterm, the Plenary Assembly sets upcommissions to prepare its work. Itdecides on the composition andpowers of these commissions.The compositions must reflect thenational composition of theCommittee. The commissions spe-cialise in particular policy areas:

• Commission for Territorial Cohesion Policy (COTER)

• Commission for Economic and Social Policy (ECOS)

• Commission for Sustainable Development (DEVE)

• Commission for Culture and Education (EDUC)

• Commission for Constitutional Affairs and European Governance(CONST)

• Commission for External Relations (RELEX)

The commissions draw up the draftversions of opinions and resolutionswhich are submitted to the PlenaryAssembly for adoption.

Secretariat-GeneralA Secretariat-General headed by theSecretary-General assists theCommittee. The Bureau ensures thatthe COR and its constituent bodiesfunction efficiently, by helping themembers of the Committee in carry-ing out their duties. It draws up theminutes of the meetings of theCommittee’s constituent bodies. TheSecretary-General is responsible forgiving effect to the decisions takenby the Bureau or the President. In

If the commission concerned cannotdraw up a draft opinion by a certaindeadline, the Bureau may proposethat the Plenary Assembly appoints arapporteur-general, who submits hisdraft opinion straight to the PlenaryAssembly. Draft resolutions or appli-cations for the drafting of a resolu-tion may be submitted to theCommittee by at least 32 members ora political group.

If the Bureau decides that theCommittee is to discuss a draft reso-lution or an application for the draft-ing of a resolution, it may either putthe draft resolution on the PlenarySession preliminary draft agenda orappoint a commission to draw up adraft resolution.

The commissions present their draftopinions before the deadline set bythe Bureau. If the commission thinksthat a document referred to it by theBureau has no regional or local inter-est, or political importance, it maydecide not to draw up an opinion.

Plenary SessionThe draft opinion (or draft resolution)is debated and voted on during thePlenary Assembly. When a deadlinecannot be met under the normal pro-cedure and the commission hasadopted its draft opinion unanimous-ly, the President transmits this draftopinion to the Council, Commissionand European Parliament for informa-tion. The draft opinion is submittedto the following Plenary Session foradoption without amendment.

The Committee’s opinions, as well asany communication related to theuse of a simplified procedure or adecision not to draw up an opinion,are sent to the Council, Commissionand European Parliament. As in thecase of resolutions, they are forward-ed by the President.

preparation for Bureau decisions, theSecretary-General draws up discus-sion documents and recommenda-tions for a decision on each item upfor discussion.

National DelegationsThe members and alternates fromeach Member State form a nationaldelegation. Each national delegationis responsible for adopting its owninternal rules and electing a chairman.

Political GroupsFour political groups are representedin the COR, which reflect the mainEuropean political families: the Partyof European Socialists (PES), theEuropean People's Party (EPP), theEuropean Liberal Democrat andReform Party (ALDE), and theEuropean Alliance (EA). These groupsprovide a forum for Committee mem-bers to discuss key political issuesand reach common positions.

Interregional GroupsMembers and alternates may alsoform interregional groups.

Execution of DutyThe Committee of the Regions is con-vened by its President at the requestof the Council or the Commission, butit may also meet on its own initiative.

Work of the CommissionsThe Bureau assigns requests foropinions (provided for in the annualwork programme) as well as requestsfor opinions on documents not con-tained in the work programme to theresponsible commission. In urgentcases, the President may designate acommission to deal with the specificmatter. If the subject of an opinionrequires the input from more thanone commission, the Bureau desig-nates a lead commission and, wherenecessary, one or more supplemen-tary commissions.

EU News


increases in survival for childrenwith serious heart defects, theassociation has stated. As a resultthere is a growing population ofadults with congenital heart dis-ease. Agfa’s new solution aims totackle this increasing problem.

KonicaKonica Work With Alliance MedicalAlliance Medical, a Europeanprovider of managed imaging serv-ices, has become the first compa-ny in the UK to install KonicaMinolta’s Drypro 793 Laser Imager.

Launched recently, this system isintegrated into Alliance Medical’sexisting PACS system. The Dryprolaser imager has a minimal pixelsize of 25 um. It is also equippedwith a web maintenance functionthat allows the user a PC on thesame network, via a web browser.In addition, it features a large LCDtouch panel with menus that areintuitive and easy to navigate.

SectraSectra receive Microsoft .NET awardSectra was announced the winnerin the category “ISV/PackagedSoftware Solutions” at Microsoft’sfifth Microsoft .NET Awards. Thecompetition acknowledges andrewards Microsoft partners thathave developed the most innova-tive IT solutions based on the .NETplatform. The jury’s motivationwas: “Sectra has developed ahigh-performance system for work-stations and servers using stream-ing technology that enables radiol-

Industr y News

ogists to gain access to radiologyimages for diagnosis”.

MatroxUpdate to Matrox ImagingLibrary AnnouncedMatrox Imaging is announcing anew module for its Matrox ImagingLibrary (MIL). “Adding a metrologytool was the next logical step forMIL”, explains Pierantonio Boriero,Product Line Manager, MatroxImaging.

As part of Processing Pack 3, thelatest update to the current MIL8.0 release, the Metrology moduletool measures and constructs geo-metric features. Users may meas-ure finite features such as arcs, cir-cles, line segments, and points inspecific image regions, and canalso construct features within theimage. In addition, users maydefine and validate tolerancesfrom dimensions, positions andshape (angularity, concentricity,perpendicularity, roundness andstraightness). The Metrology mod-ule supports calibration to obtainresults in real-world coordinatesystems.

GE HealthcareGE Healthcare CompleteAcquisition of BiacoreGE Healthcare announced that pur-suant to its public offer it hasreceived acceptances equivalent toapproximately 98 percent of thetotal number of shares outstand-ing in Biacore. All of the conditionsto the offer have been fulfilled andGE Healthcare is proceeding withthe closing of the offer.

PhilipsPhilips Hybrid ScannerImproves Cancer TreatmentA new-generation, highly advancedcombination PET/CT scanningdevice improves diagnosis andtreatment of cancers, while beingmore comfortable for patients thanolder equipment, research hasshown.

The device merges two non-inva-sive imaging technologies in one‘open’ machine. While both PETand CT scans are routinely used inevaluating cancer, the fusion of thetwo types of scans offers advan-tages over the two technologiesalone. This hybrid PET/CT scannerincorporates advances in both PETand CT technologies, and mergesthese enhancements into onefused, 3D image. The combinedimage shows up areas of metabol-ic change in their precise anatomi-cal context, sharpening diagnosticand treatment capabilities.

AGFAAgfa Debut New Solution in EuropeAt the World Congress of Cardio-logy in Barcelona, Agfa HealthCaremade the European debut of theHeartlab Congenital reporting andanalysis tool for congenitalechocardiography reporting.

Heart defects are among the mostcommon birth defects and are theleading cause of birth-defect relat-ed deaths, according to theAmerican Heart Association (AHA).Advances in diagnosis and surgicaltreatment have led to dramatic

electro photographic applications,including copying and printing.The company is Hologic’s sole sup-plier of amorphous selenium pho-toconductor coatings for Selenia™digital mammography detectors.

SiemensSiemens Helps StreamlineClinical Trial ProcessResearchers at the TechnicalUniversity of Munich and SiemensMedical Solutions have developeda method of electronically transfer-ring clinical data gathered at thepoint of care for use in prospectiveclinical trials. Through this process,clinical trial research results can bedocumented more efficiently.

This solution offers a scalable,automatic transfer of data betweenan electronic medical record (EMR)and an electronic data capture(EDC) system, overcoming interop-erability challenges associatedwith systems that operate on dif-ferent technical standards andwork within distinct business envi-ronments. Enabling immediatedata transfer, the solution is beingtested in a pilot study that was ini-tiated in June 2006. Preliminaryresults of this pilot were releasedat the ExL Pharma’s 2nd MergingElectronic Health Record and Elec-tronic Data Capture Conference inWashington, DC, and during aneClinical Forum presentation in Paris.

HologicHologic Inaugurate NewEuropean HeadquartersHologic have inaugurated theirnew European Headquarters,Service and Parts Depot, andTraining Centre in Brussels. Thenew facility doubles the size of theHologic European headquarters. This is the second major invest-ment for Hologic in Europe in thepast six months. In May, Hologicannounced the 21 million EURacquisition of AEG Elektrofoto-grafie, a privately-held companyheadquartered in Warstein,Germany. AEG develops, manufac-tures, and sells photoconductormaterials for use in a variety of

Industr y News

EU Directive and MRI scanning:The Position in the UKIn follow-up to your news piece from Prof. David Norris(Volume 6, Issue 3), this is the position in the UK at present. In2004, following an extensive review of the science and after carrying out a wide consultation, the NRPB (now the RadiationProtection Division of the Health Protection Agency, HPA) recommended adoption in the UK of the 1998 guidelines of the International Commission on Non-Ionizing RadiationProtection (ICNIRP) for EMF exposures.This recommendationwas accepted by the UK Government.

The Directive (2004/40/EC) of the European Parliament andCouncil on the minimum health and safety requirementsregarding the exposure of workers to the risks arising fromphysical agents (electromagnetic fields) incorporates some ofthe 1994 and 1998 ICNIRP guidelines. HPA is well aware ofconcerns amongst the medical profession that the Directivemight restrict some practices that utilise MRI scanning. It isimportant that such concerns are addressed, preferably withevidence-based research on the magnitude of any problem.Thiswill require a careful assessment of the exposures encounteredby staff during MRI scans. Three research projects are alreadyunderway to establish the extent of the interaction betweenmagnetic fields and MRI workers, and the EuropeanCommission will soon be publishing a tender for additionalresearch proposals.

The UK MRI community has raised questions about the basis ofICNIRP guidelines for low frequency magnetic fields, particular-ly the limiting physiological response.A review of guidelines forstatic magnetic fields and time-varying fields of frequencies upto 100 kHz is currently being undertaken by ICNIRP. Thesefields and frequencies include those produced by MRI scanningequipment.

The implementation of the Directive in the UK is the responsi-bility of the Health and Safety Executive (HSE). Neither HPA,nor its predecessor NRPB, were involved in the legislative andnegotiation process related to the development and agreementon the EU Directive. This was the responsibility of UKGovernment Departments and regulatory bodies.

More information can be found on the following websites:1.A F McKinlay, S G Allen, R Cox, P J Dimbylow, S M Mann, CR Muirhead, R D Saunders, Z J Sienkiewicz, J W Stather and PR Wainwright (2004). Review of the Scientific Evidence forLimiting Exposure to Electromagnetic Fields (0–300 GHz),Documents of the NRPB:Volume 15, No. 3, 3-209.http://www.hpa.org.uk/radiation/publications/documents_of_nrpb/abstracts/absd15-3.htm2. NRPB (2004),Advice on Limiting Exposure toElectromagnetic Fields (0–300 GHz) Documents of the NRPB:Volume 15, No. 2,1-35.http://www.hpa.org.uk/radiation/publications/documents_of_nrpb/abstracts/absd15-2.htm3. MRI – EC Physical Agents Directive on HPA Website athttp://www.hpa.org.uk/radiation/understand/information_sheets/mri_ec_directive_2004_40_ec.htm4. ICNIRP website at http://www.icnirp.org/workplan.htm5. HSE website at http://www.hse.gov.uk/radiation/nonionising/electro.htm6. EU Directive athttp://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32004L0040R(01):EN:HTML

Dr M J ClarkCentre for Radiation, Chemical and Environmental HazardsHealth Protection AgencyOxon, UK

L e t t e r s t o t h e E d i t o r


The modern medical record can be conceived ofas a portal, which can deliver information to thepoint of care. The information should consist ofboth textual and multimedia data requiring seam-less integration of narratives and medical imag-ing. With suitable terminals, physicians in clinicalwards can access images from the bedside.

Mobile TeleradiologyMobile teleradiology interpreting units are basedon different technical platforms ranging from lap-top computers to mobile phones. Most promisingterminal types for medical purposes are smart-phones with computer functions, personal digitalassistants (PDA) with phone capabilities or tabletPC devices with networking capabilities. Variouswireless networks are available ranging fromwireless computer networks (WLAN or WiFi) tomobile phone networks (GSM, GPRS, EDGE orUMTS). A common platform today is mobile IPtechnology, or the mobile internet.

Mobile teleradiology terminals have so far beenmostly used for viewing images needing a sec-ondary consultation. At the Oulu University hos-pital in Finland, since 2000, our neurosurgeonshave made their decisions based on emergencyCT image data before even entering the hospital.This is done using smartphone terminals special-ly developed for this purpose in EU-fundedMOMEDA and PROMODAS projects. An importantaspect has been to transmit radiology informa-


tion system (RIS) and hospital information sys-tem (HIS) data together with images. For theirpurposes, image quality and speed of servicehave been satisfactory enough to facilitate a newtype of consultation policy.

Benefits of Mobile DevicesThe benefit of mobile devices is greatest if theycan be connected to a comprehensive electronicpatient record (EPR). In hospital wards, radiolog-ical images are one part of electronic patientinformation including narrative texts, referral let-ters, laboratory tests and biosignals. Most mobileEPR terminals are still laptop computers withordinary displays and a WLAN.

Limitations Mobile terminals still have technical limitationsincluding small display size, limited battery life,slow processors and thus reduced computationalpower. Also the network speed, availability andcosts can generate obstacles. The small displaymatrix and less-than-optimal colour spectrumusually limits the use of ordinary mobile cameraphones for teleradiology. The more expensivesmartphones can usually be equipped with soft-ware that enables better image manipulationcapabilities. Unfortunately, these are usually notsuited for standard DICOM images. The smallmatrix is the reason why mobile terminals havebeen mostly used for CT and MRI scans. They arenot suited for primary reading, because diagnos-

MOBILE IMAGE DELIVERY AND ACQUISITIONNew Ways to Manage and Access Information

AUTHOR

DR JARMO REPONEN

CHIEF RADIOLOGIST

DEPT. OF RADIOLOGY

RAAHE HOSPITAL

RAAHE, FINLAND

[email protected]

The development of wireless networks and terminals has

made mobile connections to image archive and communication

systems (PACS) a reality. This access is now possible outside

the fixed hospital network and even outside the physical

hospital boundaries. This article explores the benefits of new

terminal devices as well as current limitations, and how mobile

image acquisition can result in a real virtual hospital.

Cover Story Mobi le Informat ics in Radiology


tic image manipulation and comparison with pre-vious images is seldom possible. If the displaymatrix is increased, the result is an increasedpower consumption and thus heavier equipmentand shorter operational time.

Mobile Telecom NetworksEven though mobile teleradiology is feasible for special purposes, current second generationmobile telecom networks (GSM and its evolutionsGPRS and EDGE) still provide rather slow datatransfer speeds. Emerging 3G networks (UMTS)may break this barrier, bringing broadband tomobile devices. The main limitations for UMTSare the price of connections and limited availabil-ity in many European countries. Also its topspeed is not comparable with fixed networks.

Another interesting wireless broadband technolo-gy is WLANè. In an earlier project, we saw howusing a tablet PC system made data access fastand comparable with terminals connected to thehospital network. The main limitation of WLAN isthat outside the hospital campus area it is avail-able only in so-called service points, “hot spots”.Thus, WLAN is not suitable for health profession-als that are on-duty and have to be able to con-nect to the hospital at any time.

Finally, transmission costs may influence choiceof a network. Because image files are large,mobile phone networks are usually quite expen-sive, despite the possibilities offered by flat feemonthly agreements.

The capabilities of handheld devices are reachinglevels needed for many medical imaging require-ments. However, we are in a rapid developmentphase for mobile technology, and the life ofmobile devices is rather limited. For these rea-sons, the development costs of consultation sys-tems may be high compared to the expectedusage of the applications. Therefore, a carefulsystem design is needed.

Security issues are still more difficult to resolvein a mobile environment than in a fixed network. Itis imperative that no patient identification data isreleased. Due to this, the buyer who purchases hismobile terminals as an add-on tool to his existingPACS and EPR system and not as a stand-alonesystem is wise.

From a radiological view point, mobile imageacquisition is also possible. In Norway, at theUllevaal University Hospital, they have an exten-sive experience of serving nursing homes with amobile digital radiographic imaging equipment.New technology has made it possible to take theimaging equipment to the patients and transmitresulting images to interpreting radiologistswhenever a network connection is established.The boundaries of a virtual department are nowa-days quite extensive. Mobile teleradiology servic-es can be utilised to their full potential only ifthey are integrated with electronic patient recordsystems. The patient is the final winner whenmedical professionals can deliver and accessinformation in the most practical way.

❚ ❚ ❚Cover Story Mobi le Informat ics in Radiology


AUTHOR

DR HENRIK GREGERSEN

CHAIRMAN

MUSCULOSKELETAL RADIOLOGY

SECTION

DEPARTMENT OF RADIOLOGY

AALBORG HOSPITAL

AALBORG, DENMARK

[email protected]

Going Mobile in Aalborg Under the auspices of a national and EU projectcalled the Digital North Denmark, the County ofNorthern Jutland sought digital technology sys-tems that allowed free and unhindered access toimages and other patient data. The aim was togive healthcare professionals tools to supporttheir way of working, instead of forcing staff toadapt to IT systems.

Radiologists and clinicians were equipped with awireless PDA, on which they could search thePACS for image data and get access to the writ-ten report. There is also a project going on toimplement RIS functionality on the wireless sys-tem. Nearly all PCs in the hospital allow unhin-dered access to all image data and functionality.

The RIS-PACS system enabling this uses stream-ing technology to distribute the image data(EasyViz, Medical Insight, Hedehusene, Denmark).All computing facilities, reconstructions and PACSand RIS functions are performed on a centralserver and the only data transfer to the user isthe screen signal. This means there is no imagedata transfer, or large datasets to send via thenetwork.

The Perfect Teleradiology SystemFrom very early in the process, the ultimate goalwas to establish a system giving the user theperfect teleradiologic system with:

• Real-time access to radiology data and patient information;

• Unrestricted use of wireless and mobile devices;

• Availability of diagnostic tools and functions;• Equal access, functionality and performance

whether on-site or remote.

This goal has now been achieved, enabling me to

work from any PC in the hospital, from any wire-less access point on a PDA or laptop computer.

This gives me free choice of location and hard-ware for any given task. Most reporting is per-formed on my office PC, as most of my readingis MRI and CT. X-rays are more often read ondiagnostic workstations. I can also work fromhome. On a 2MB internet connection, there is aslight delay in the manipulation of the images,but the functionality is the same on my home PC,PDA or on the office PC. This saves time, espe-cially in situations where several examinationsneed my attention simultaneously. The PDA ismostly used for orientation, but diagnostic workcan be performed, at least for MR and CT images.

Limitations can, however, arise. Since practicallyall users are moving around the facility, oraccessing the system from outside the institu-tion, it must be made easy for each user to movefrom one computer to another or the systemmust be wireless. Moving from one computer tothe next is, in an office setting, difficult. If itproves difficult to move your application fromone computer to another, no one wants to move.

ConclusionAdoption by clinicians has been mixed. Severalclinicians are not availing of the wireless applica-tion, as either they are unaware of the function-ality or prefer to use a stationary computer.Reactions to the use of PDAs are mainly scepti-cism about screen size or resolution, as well asbattery life and the fact that input on a PDA istroublesome. Today, the vast majority of imagesare viewed on a PC. Few diagnostic workstationsexist in clinical settings. This means a consider-able saving for the hospital, and considerablyeasier viewing possibilities for the clinicians, asclose to the patient as possible.

The healthcare environment is constantly changing. From paper reports and films, which

facilitated patient contact, professionals then embraced digital data processing systems,

for the most part not as a true digital patient record, but as fragmented systems.

Nowadays, doctors and nurses are spending increasing time with computers, and have less

time with patients or colleagues. To prevent isolation, going mobile is a new and exciting

development that will remove the limitations of a previously rigid digital healthcare envi-

ronment, and support best workflow.

Our Experience Integrating Mobile Technology

THE DIGITAL NORTH DENMARK PROJECT

Cover Story Mobi le Informat ics in Radiology❚ ❚ ❚


AUTHOR

LIZ BECKMANN

MANAGING DIRECTOR

LANMARK MEDICAL

BEACONSFIELD, UK

LIZBECKMANN@

LANMARKMEDICAL.CO.UK

Constraints on the transmission of images havechanged significantly. Ten years ago, a standardtelephone line was capable of transmitting onlyat speeds of around 2.4kbps and is nowadaysstill restricted to around 56kbps. The introduc-tion of ISDN improved transmission speeds to128kbps; but with multi-slice spiral CT, the size ofthe data sets increased to the order of 500-700slices, with the result that transmission time signif-icantly increased and became an even greater issue.

Broadband ADSL, operating at up to 8Mbps, hashad a huge impact in alleviating this problem;however, the benefit is in one direction only. Thedownload to a remote computer has improved;but any upload from a computer to the internetis slower.

Security RisksThe impact of moving data around by mobiletechnology means that security and patient con-fidentiality are of paramount importance. Issuesare similar whether images and patient data arebeing transmitted around the UK or overseas.Whilst VPNs offer a degree of security, they areexpensive and exclude the ability to send datafor a specialist second opinion.

Companies are working on the application ofresilient encryption technology which enablesdata files to be sent across intranets and theinternet with a high degree of security and insuch a way that only the authorised recipient candecrypt the data, even if it is stored in encryptedform on a remote computer.

Viewing NeedsOne of the greatest challenges of going mobile isthe quality of the receiving viewing unit. In com-parison to a basic computer which can achieveresolution of 1280 x 1024, many mobile devicessuch as PDAs, have a resolution below 480 x640. Although it is possible to view images inquadrants with roam and zoom, this is neither

ideal nor clinically acceptable. Mobile access canbe provided to image data for a user without theneed for dedicated mobile equipment; forinstance using a PC connected to an intranet orthe internet. Also, laptop computer systems whilenot as portable as PDAs offer screens with betterresolution and higher processing power.

Data access over an intranet, the internet or VPNcan work in different ways. Firstly, where theremote user downloads images onto their ownsystem. Here the issue of the security of the dataon the remote machine becomes important, andissues such as who has access or how long datais retained must be controlled.

Alternatively, remote users can access and viewimage data which is held on a central server. Insuch cases, the speed of the connection is impor-tant in defining response time for any manipula-tion carried out by the user on the data. On largedata sets these time delays can pose a problem.

Technology Trends To achieve a viable, lightweight device for mobileapplications, there is a need to develop light-weight and high power displays and increase pro-cessing power, memory size, and battery power.One of the greatest problems is current batterytechnology. To get an operating time of severalhours, batteries are bulky, and even then, needfrequent access to mains power for recharging.This is an issue which seriously needs addressingif we are to achieve true mobility in imaging.

As imaging develops, challenges increase. Bothdata sets and the complexity of data manipula-tion required has increased. The ability to fuse orcompare image studies and rotate images in realtime requires significant computing power, whichis a problem with compact mobile devices. Whilstthese facilities are not required in all cases orapplications, they often add significant benefitfor patient management.

ENABLING ACCESS TO PATIENT DATA Ensuring True Mobility in Imaging

Mobile imaging is not new; for over ten years, it has been used in several areas, including the trans-mission of trauma CT scans for on-call reporting by radiologists at home or for emergency referral to a tertiary centre. It has also been used to enable smaller hospitals in remote areas, often without radiological cover, to transmit x-ray images to a major hospital for a second opinion, to enable optimum patient management.


Defining Mobile RadiologyNowadays, all one requires is a local area net-work (LAN) system connected with a pocket PCor personal digital assistant (PDA) to be includedin the gamut of mobile radiology. This system istermed the Mobile Radiology Information andTelemedicine System (MORITS). System configu-ration comprises of a mobile DICOM server andPDAs. Connection from PDAs with the DICOMserver can be obtained via the LAN. The Linux-based Mobile Dicom Server (MDS) can beaccessed with PCs and PDAs by means of a wire-less or wired LAN access point, and an Ethernetbridge can be attached to the MDS.

Displaying ImagesDICOM images can be displayed by using anyPDA or PC by means of a web browser.Simultaneous access to the MDS is possible formultiple authenticated users. Mobile PC and PDAclients are connected to the MDS over a wirelessLAN (802.11), with a maximum of 250 clients con-nected simultaneously. With most PDAs, imagecompression is necessary for complete display ofDICOM images. This wireless system allows effi-cient management of heavy loads of losslessDICOM image data and is useful for collaborativework by radiologists in education, conferencesand research.

In our system, three types of PDA clients areused: a Linux PDA, the Pocket PC (Microsoft,Redmond, WA), and the Palm OS (PalmSource,Sunnyvale, CA). Our PACS archives containDICOM images in various resolutions from 256 x256 pixels to 2,140 x 1,760 pixels. The standarddisplay resolutions of common PDAs are 320 x240 pixels for the Pocket PC and 480 x 320 pix-els for Palm OS version, and as non-compressedDICOM images exceed these common PDAdisplay sizes, it is necessary to use compressedimages to display the whole image on thesePDAs. In using the pocket-sized MDS, the systemuses two basic network modes: a closed person-

al network environment and a network connect-ed to an existing LAN. Our MDS is used as ashort-term DICOM archive for teaching files foruse in education and research. To store DICOMimages in the MDS, users connect through anexisting wired LAN. After archiving target DICOMimages each user carries their own personalaccess device, allowing co-authors to shareimage data directly using the MDS without copy-ing or burning CDs.

Security ConsiderationsThis system is not without certain security con-siderations. For example, when the MDS is start-ed, a digit code is requested. A basic web serversecurity code is installed in the MDS and a HTTPbasic authentication requires the client to send auser name and password in clear text as part ofthe HTTP request. Another security system isradiofrequency (RF) power control of the signalstrength: the RF power of the wireless LAN canbe set from several to approximately 50 metres.To secure the wireless LAN, a low RF power mustbe selected. Currently, wireless LAN security is a work in progress. There are three basic meth-ods in 802.11 networks for securing accesspoints: extended service set identifier (ESS-ID),media access control (MAC) address filtering andthe wired equivalent privacy (WEP) encryptionmechanism.

Advantages and DisadvantagesThe advantages of PDAs in radiologic work aremany. They are small and portable. Radiologistscan communicate using handheld devices com-patible with wireless communication networksfrom outside areas. Images and diagnoses can betransferred as different files, such as MicrosoftExcel or Word files for teaching and education.Radiologists can use PDA or PC clients to accessthe MDS. Storage of images can be read both forpersonal and group work for research. With theseadvantages, MDS is more beneficial than conven-tional PACS.

MOBILE LIFE IN THE RADIOLOGY DEPARTMENTOur Experiences With Mobile Technology

Workflow dynamics within modern radiology departments have transformed with the growing

influence of information technology, of which the most significant additions have clearly been

DICOM image data systems, PACS, Radiology Information Systems (RIS), Hospital Information

Systems (HIS) and teleradiology.


AUTHOR

PROF. NEVRA ELMAS

PROFESSOR OF RADIOLOGY


EGE UNIVERSITY MEDICAL

FACULTY

IZMIR, TURKEY

[email protected]


Moving Images AroundIn clinical settings, physicians rely more andmore on images and image data for patient man-agement and clinical decisions, therefore theyexpect to have rapid access to digital images atthe point of care. Many technical solutions areemerging as alternatives for remote access toimage data.

Image Access on Portable ComputersThe development of higher performance laptopand tablet computers allows more efficient man-agement of large volumes of data with sufficientprocessing power for image manipulation andprocessing. Besides, the development of solu-tions based on thin-client technology allowsremote laptops access to image processing andvisualisation tools remotely from central serversthrough web-based or thin-client applications.These recent evolutions have led to more widelyaccepted solutions of remote image access viaportable devices such as tablet PCs (see fig. 1).

The convenience and performance of these toolsopens a new era of clinical applications that canbenefit from the mobility of these devicesthrough wireless technology while maintaining


enough performance to be suitable for clinicalrequirements and management of large imagedata sets. Several prototypes of such implemen-tations have been reported using web-basedimage viewing applications. More recently,advanced image processing and rendering toolshave become accessible on portable computersdue to the rapid improvement in performance ofthese devices.

Handheld Devices and PDAsNumerous systems were developed to allowextracts of electronic patient records (EPRs) to bedownloaded and stored in handheld devices tobe readily accessible when needed. Wirelesscommunication provides the added convenienceof direct access to central data repositories andsources of on-line information. Our experiencewith handheld devices for displaying medicalimages shows that today’s handheld devices suf-fer from three major limitations: low display res-olution, low storage capacity and relatively limit-ed communication speed.

In an effort to explore an alternative solution thatcombines the convenience of a handheld devicewith the quality and performance of high-resolu-tion image display systems, a project developedat UCLA explored an innovative concept for imageretrieval and display in clinical wards. The systemis designed to replace existing lightboxes in clin-ical wards with high-resolution, wall-mounted flatpanel display devices driven by handheld PDAdevices that can initiate the query and retrievalof specific medical images and documents fromremote storage archives (see fig. 2, page 24).

With the increasing size of image studies such asmulti-detector CT, functional MRI, and multi-

WIRELESS ACCESS TO PATIENT RECORDSIN A CLINICAL ENVIRONMENTOverview of Emerging Trends

While mobile access to medical data and patient is becoming more widely available, accessingimages still represents a technical and logistical challenge. Demand for remote image access isincreasing dramatically. Solutions using wireless technology and improved performance ofportable computers allow more realistic implementation of mobile alternatives than conventionalimaging workstation, particularly for clinical wards and bed-side patient care. This paper reviewssome emerging trends for more convenient mobile access to image data.

AUTHORS

DR DAVID BANDON

DIGITAL IMAGING UNIT HEAD

PROF. OSMAN RATIB

HEAD OF NUCLEAR MEDICINE

DR ANTOINE ROSSET

RADIOLOGIST


AND MEDICAL INFORMATICS

UNIVERSITY HOSPITALS OF

GENEVA (HUG)

GENEVA, SWITZERLAND

[email protected]

Fig. 1: Example of

tablet PC with image

visualisation capabili-

ties (Centricity

Radiology Web soft-

ware from GE Medical

Systems)

•• continued on p.24


The UK’s “Outsourced Imaging” Model

According to a recent study by a European man-agement consultancy team, Britain is the globalleader when it comes to getting the best from“outsourcing”, i.e. using the private sector todeliver public services. In the UK, theGovernment’s commitment to providing greateraccess and choice for patients, combined with awillingness to develop plurality of providers, irre-spective of their public or private status, has ledto the widespread recognition of the benefitsoutsourcing can bring to both patient and health-care institutions alike.

Mobile Imaging

Today, many hospitals not only in the UK but alsoacross Europe are turning to mobile imagingsolutions. In turn, mobile imaging is becomingever more flexible and comprehensive. The use of

a mobile interimservice ensuresthat hospitalscan respondquickly to devel-oping situationsin an economi-cal manner, withunits beingused only forthe requiredamount of time.


Such services are especially important when hos-pitals are upgrading existing systems or installingnew ones. Furthermore, as hospitals can usetheir own staff in the units, they can be sure ofmaximum continuity of systems, with minimumimpact on budgets.

Where imaging demand does not justify a newsystem installation, or where imaging demand ispermanently high, fully managed mobile serviceswith highly trained radiographers, either as aone-off solution or a long-term aid, offers ‘a valuefor money’ solution.

Conclusions

Whether fixed-site or mobile, fully managed oroperated by existing hospital staff, outsourcedimaging provides hospitals with a solution tai-lored to their needs. With the expansion of theEU, hospitals in new EU-member states will soonbe able to open their doors to the technologiesand services that are becoming central to health-care in Western Europe.

OUTSOURCED DIAGNOSTIC IMAGING SOLUTIONSDevelopments in medicine over recent years have meant that hospitals in Europemust increasingly rely on state-of-the-art technologies. Patients have come toexpect the best, not only in terms of a fast diagnosis, but also in the use of themost up-to-date technologies.

Dr Arpan K. Banerjee, MBBS FRCP FRCR, Consultant Radiologist in the UK at theBirmingham Heartlands and Solihull Hospitals NHS Trust, explains the benefitsthat outsourcing radiological requirements can bring to public and private health-care providers.

AUTHOR

DR ARPAN K. BANERJEE

MBBS FRCP FRCR

CONSULTANT RADIOLOGIST

BIRMINGHAM HEARTLANDS

AND SOLIHULL HOSPITALS

NHS TRUST

UNITED KINGDOM

For further information, please contact:Alliance Medical GroupHome Farm Drive Upton, Nr. BanburyOxon OX15 6HU, UK

tel: + (44) 1295 671 253fax: + (44) 1295 671 233e-mail:[email protected]

Corporate Presentat ion


modality PET/CT, the size ofdata tends to exceed thecapacity of traditional media,and therefore, alternative solu-tions for convenient trans-portation of large image dataare urgently needed.

We selected general consumerproducts recently released byApple Computer for their wideavailability, low cost, conven-ience and ease of use. Wespecifically adapted them formedical imaging applications.The iPod was integrated toserve as a high-capacityportable DICOM storage withhigh-speed transfer rate. Itintegrates a fast and high-capacity hard disk to store up

to 40GB of data. It can be connected to any com-puters with a FireWire 400 (IEEE 1394) or a USB-2 interface.

Transmission speeds of these interfaces are up to400 and 480 Mbits/s, respectively. OsiriX softwarewas adapted to automatically detect when aniPod is connected to the computer and automat-ically updates its local DICOM database to dis-play the studies available on the iPod disk. Userscan also copy image data from and to the iPod.With the recent generation of iPod photo devices,it is also now possible to display colour imageson the screen.

Clinical Applications of Mobile TechnologiesIn emergency rooms, there are several situationswhere images can be acquired directly at thebedside. Portable ultrasound as well as endo-scopic devices can generate digital images to betransferred to remote consultation locations. Inmost cases, image transfer requires a physicalconnection to a network which limits smoothworkflow. Also, image acquisition often needs toquery the patient’s worklist before going to thepatient location with the imaging device, whichcan mean further limitations.

Once images are acquired, the acquisition devicemust be physically reconnected to a networkplug to transfer images to the PACS. At our hos-pital (HUG), we encountered recurrent problemslike broken network cables disrupting communi-

cation or the need to manually reconcile imageswith the patient’s file when the physician failedto retrieve patient demographics before theexam. Thus, we adopted mobile technologies(MT) for image acquisition, in Spring 2006,launching a pilot with one mobile endoscopicdevice for urgent gastroenterology exams.Results are satisfactory with no manual reconcil-iation needed and, in general, less problems.

Wireless networks and mobile carts permit bed-side patient data entry and provide image pre-views in emergency rooms and clinical wards viawireless networks. The department of paediatricsat the HUG is our pilot site for extending filmlessoperations outside of radiology. A user satisfac-tion survey showed that the vast majority ofphysicians would not revert to film except in spe-cific cases for 35% who pointed out that imageaccess in OR and clinical wards was less thanoptimal due to ergonomic problems. Wirelessaccess was the non-prompted solution mostoften quoted. The fact that physicians sponta-neously suggested wireless to improve their workenvironment is an important element in favour ofMT. While wireless distribution to wards has beeninitially implemented for computerised physicianorder entry (CPOE), we will now include imageaccess from laptops.

ConclusionThe main challenge to implement mobile tech-nologies (MT) in wards is performance. Both thenetwork and the wireless system must scale forbandwidth for the heavy traffic load. At the HUG,the first system utilised the 802.11 technology(Wifi with a bandwidth enabling 11 Mbit/s) deliv-ering only 1 to 2 Mbit/s. A chest x-ray was avail-able after 45 seconds, which is too slow to beused in clinical routine at the bed-side. A currentupgrade to new 802.11 technology (54 Mbit/sec.),combined with the use of image quality ondemand, improves performance. Encouraged byour positive experiences with MT, we will beadopting them widely to ensure adequate imple-mentation in response to the needs of eachdepartment. We anticipate that cost efficiencystudies will be required to justify the initialinvestment of MT. It is our conviction that MT isa natural extension to the filmless and paperlesshospital and will better support physicians intheir routine activities.

References for this article are available at: [email protected]

Fig. 2: Pocket PC (1) communicates with theflat panel display device (2) via an infraredchannel (3). The additional touch pad device(4) is mounted next to the flat panel devicefor manual image and display functions.



Ultrasound in OncologyUltrasound is providing clinicians the ability tomore accurately quantify the size and nature oftumours as well as help assess whether they arebenign or malignant. The result is earlier andmore confident diagnosis by the physician aswell as a potential reduction in the number ofcostly biopsies required.

Ultrasound and the BreastIn the western world, more than 1 in 10 womencurrently develop breast cancer. Approximately70% of these cancers are a particular type oftumour known as an invasive ductal carcinoma.Currently, the only way to confirm whether thesegrowths are really malignant is to perform a biop-sy, an expensive and time-intensive procedure.

A universal characteristic of malignant tumours isthat they stimulate a process in the body knownas angiogenesis. Microvascular imaging (MVI)using ultrasound is a quick and cost-effectiveway for clinicians to image these blood vesselssurrounding a tumour to determine whether it ismalignant or benign. A contrast agent (SonoVue,Bracco Diagnostics Inc.) with a suspension ofmicro-bubbles is injected into the bloodstream.The MVI then captures a sequence of images thatare assembled into a ‘movie’. The resulting imagevisualises the presence of angiogenesis or not.

3D Breast ImagingAnother way ultrasound is facilitating cost-effec-tive lesion analysis is using ‘volumetric’ imaging,obtaining a full volume of tissue data and exam-ining it in multiple dimensions. Using 3D, thephysician can better assess a breast lesion’s bor-ders and characteristics as well as study the sur-rounding breast tissue that could help in diseasemanagement. Visualisation techniques like pro-gressive precision slicing of a volume to generate2D images can also help the clinician quicklyevaluate breast tissue. Future visualisation tech-nology will allow segmentation of the lesion fromsurrounding tissue and automatically assesscharacteristics of the lesion to determine mass

size, shape, internal properties and orientation tobreast architecture.

These lesion quantification technologies mayalso play a valuable role in therapy and post-operative care. Following a lumpectomy or ablation,they can help differentiate between scar tissuearound the surgical site and new tumour growth.

Liver Tumour AblationLiver tumour ablation is an evolving applicationbeing used by interventional radiologists andoncologists. Using ultrasound guidance, physi-cians can locate tumours and destroy them with-out resecting large portions of the liver. Used asa 3D guide, ultrasound can pinpoint the size andlocation of a liver tumor and guide the placementof an ablation needle that uses a radiofrequency(RF) current to destroy the cancerous tissue.Following the RF ablation procedure, ultrasoundimaging helps evaluate and assess the procedureto determine whether it was a success.

FertilityIn patients with infertility or who are experienc-ing repeated spontaneous abortions, volumetricimaging can help the physician identify thecause(s) and condition(s) that led to infertility. 3Dultrasound is superior to conventional scanningtechniques as the entire uterine volume can beacquired and interrogated to produce uniqueviews of the uterus and surrounding anatomythat can help assess malformations that may leadto infertility. Volumetric ultrasound is also usefulin performing sonohysterography to examinethickened endometrium, to identify the locationand number of polyps, abnormal bleeding oradhesions.

Volumetric multiplanar imaging provides moredetailed assessment since it offers a coronalplane view, giving better visualisation of the uter-ine anatomy to precisely pinpoint the abnormali-ty. The coronal view captured by 3D ultrasoundalso provides a better image of cornual and cer-vical ectopic pregnancies.

Beyond the heart, researchers are exploring applications for 3D or “volumetric” ultrasound technol-ogy to help improve the physician’s diagnostic and treatment decisions. The following are just a fewareas in which ultrasound shows real promise for a variety of conditions.

BEYOND THE HEART:

INNOVATIONS IN RADIOLOGYThe Evolving Ultrasound Market

Features

AUTHOR

DR JIM R. BROWN

SENIOR DIRECTOR OF CLINICAL

AND TECHNICAL MARKETING

PHILIPS MEDICAL SYSTEMS,

ULTRASOUND

Erratum!In the last issue of IMAGING

Management, our feature

on 'Power Injectors in

Computed Tomography’

mentioned Tyco Healthcare’s

‘Optivision DH’ product.

It should have mentioned

‘OptiVantage DH’.

Live volume imaging allows the acquisition and immediate display of a volume of ultrasoundin true real time. Using this new technique clinicians can rotate, look above or under struc-tures without moving the transducer – something not possible using conventional 2D ultrasound. This is especially helpful when evaluating complex anatomical structures and spatial relationships.

Ultrasound and the MusculoskeletalSystem Sports medicine, and the viewing of the muscu-loskeletal system (MSK) has benefited from ultra-sound, which provides a safe and powerfulmodality for viewing superficial soft tissues suchas tendon injuries. Ultrasound’s high resolutionprovides an unbeatable view in diagnosing rup-tures, adhesions or tendonitis of the Achilles ten-don, biceps, thumb, quadriceps, patellar tendon,or rotator cuff. Ultrasound also is ideal in evalu-ating the mystery surrounding sports hernias andproviding detailed interpretations. The ability tolook closely at moving tendons in the hand is ofsignificant clinical benefit to orthopaedic andhand surgeons preparing surgical plans to repaira specific injury.

Features ❚ ❚ ❚

The most useful role for MSK ultrasound in theclinic is as an extension of a physical examina-tion. Additionally, it can be used to evaluate jointdynamic and static stabilizers to assess joint syn-ovitis or fluid, and to identify the exact site fortherapeutic modalities and direct needle place-ment for aspiration or to deliver local anaesthesia.

Ultrasound is ideal when integrated with MRI andCT. General or vague pain can be imaged usingMRI. Once a specific injury is located, ultrasoundor CT can be used to make a definitive diagnosis.

ConclusionIn summary, the advent of new technologies suchas live volumetric imaging, advanced visualisa-tion and quantification are moving ultrasoundfrom a purely diagnostic imaging tool to one thatis aiding the physician in making treatment deci-sions, guiding procedures and providing cost-effective patient management. Ultrasound is rap-idly changing the way healthcare is delivered,improving patient care while reducing costs forhealthcare providers. The more we as clinicians,interventionalists and surgeons can learn as aresult of this technology the greater the impacton disease management and patient outcomes.

How Can 3D Reduce Costs?Increased diagnostic sensitivity across all special-ties and the likelihood of shorter OR time perprocedure contribute to reduced costs. Thusquality of care is greatly enhanced, often with adecrease in cost compared to alternative proce-dures. For example, prior to the establishment of3D imaging services at our institutions, standardprotocol for assessing laproscopic living renaldonor candidates involved a catheter angiogramto assess the renal vasculature (number, location,and relation among renal arteries and veins) plusan intravenous pyelogram (IVP) to assess theconfiguration of the ureters and renal collectingsystem.

These procedures involved exposing the patientto significant health risk involving anaesthesia,catheterisation, as well as high radiation dose,and several thousand dollars in costs for bothprocedures. Through 3D imaging post-processingof high-resolution CT scans, the current protocolinvolves a CT angiography scan (CTA) to assessthe renal vasculature in place of the catheterangiogram, plus a delayed phase CT urogram(CTU) which replaced the IVP, and both the CTAand CTU are acquired in a single outpatient CTcontrast study (see Fig. 1).

Thus, a single, contrast-enhanced CTA/CTU outpa-tient procedure, costing a few hundred dollarswith minimal risk and exposure to the patient,has replaced two expensive and invasive proce-dures costing several thousand dollars andexposing an otherwise healthy patient to signifi-cant risk. Ultimately, 3D imaging providespatients with improved care, significantly lowerrisk and cost and improved diagnostic clarity.

Potential Uses for 3D Imaging3D imaging services have become an integralpart of the clinical workflow for radiologists andreferring clinicians in many hospitals as they can

MDCT has opened new possibilities andincreased demand for 3D imaging. Rapid acquisi-tion using thin slices and improved renderingalgorithms facilitates exquisite 3D images andreformats. However, review of the ensuing largenumbers of images from modern MDCT and MRscanners, often hundreds or even thousands ofslices per study, pose significant challenges toradiologists’ efficiency. Having 3D capability avail-able for diagnosis and surgical planning allowsradiologists and referring physicians to get asummary view of the entire anatomy in a fewconcise, anatomically clear 3D views, and thenrefer back to the original 2D data for comparisonand confirmation. Thus, 3D reconstruction ismore frequently becoming a valuable techniqueto summarise in a concise and clear way theoverwhelming number of slices produced bymodern CT and MR scanners.

3D medical imaging has revolutionised both radi-ological diagnosis and surgical planning. 3Dreconstructions provide life-like views that canquickly summarise the relationship amonganatomic structures for planning surgical proce-dures before and within the OR. Benefits includedecreased exploratory time in the OR, less dam-age to healthy tissues, and a lower risk of com-plications for the patient, all of which contributeto reduced surgical morbidity.


PACS soft-copy reading, as with film reading, has traditionally been limited to viewing the transmis-sion of cross-sectional images in fixed orientations as provided by the original scan. Improvementsin the speed, usability and affordability of 3D workstation hardware and software, and improvementsin integration of 3D software within PACS, means it’s now possible to apply computer image process-ing techniques for 3D imaging and CAD within routine clinical workflow to provide 3D imaging withina PACS environment.

HOW 3D IMAGING IS ADVANCING RADIOLOGYPractical Guidelines for a Successful 3D Imaging Service

AUTHORS

GORDON J. HARRIS

DIRECTOR, 3D IMAGING

SERVICE

MASSACHUSETTS GENERAL

HOSPITAL

ASSOCIATE PROFESSOR OF

RADIOLOGY

HARVARD MEDICAL SCHOOL

BOSTON, MA

USA

[email protected]

MATTHEW A. BARISH

DIRECTOR, 3D AND IMAGE

PROCESSING CENTER

BRIGHAM AND WOMEN’S

HOSPITAL

ASSISTANT PROFESSOR OF

RADIOLOGY

HARVARD MEDICAL SCHOOL

BOSTON, MA

USA

Features❚ ❚ ❚

Fig. 1: Left: CTA of the renal arteries. Right: CTU of theureters and collecting system. Both images were createdfrom the same CT contrast scan session, with one contrastbolus at different time delays and depict high-resolutiondetails required in assessing renal donors for transplants.

CTA showing a double aneurysm at thetop of the basilar artery on cerebralCTA, which can replace catheterangiography for assessing cerebralaneurysms.


process exams for a variety of sub-specialtiesincluding vascular, orthopaedic, chest, breast MR,GI/GU, emergency and paediatric exams. In addi-tion, a variety of neurology, neurosurgery andoral-maxillofacial exams are reconstructed with3D imaging, including brain surface renderingsfor neurosurgical planning, CTA for stroke andaneurysm imaging, brain tumour volumetricmeasurements, imaging of craniosynostoses andcomplex facial fractures/trauma.

3D reconstructions are also essential to vascularimaging. For example, aortic aneurysm, liverresection and living liver and renal donor assess-ments are greatly aided by pre-surgical 3D imag-ing of CT or MRA vascular evaluation and treat-ment planning on computer rather than explo-ration in the OR. 3D imaging is also effective inassessing pancreatic cancer and associated vas-cular involvement and for virtual endoscopy, suchas colonography or bronchography.

Many complex 3D exams, CTA for example,require 45 to 60 minutes or more to process allthe associated views, while other less complicat-ed 3D exams may take only 15 to 30 minuteseach to process. If the clinical volume at a facili-ty is sufficient, it is cost-effective to have one ormore dedicated 3D technologists process theseexams or alternatively outsource the 3D imageprocessing.

What to Look for in a 3D TechnologistA dedicated 3D technologist should be hired asan experienced, certified CT or MR technologistwho can work closely with the radiologists andreferring physicians to create 3D protocols thatgenerate the most useful views for each type ofexam. The 3D technologist must understandcross-sectional anatomy and pathology in-depth,as well as scan artifacts, and must learn to oper-ate complex computer software. The trainingperiod for a dedicated 3D technologist thusranges from 3 to 6 months at our institutions.

One consideration in determining the cost-effec-tiveness of the service would be the cost of nothaving a dedicated 3D imaging service. For exam-ple, if a radiologist spending a few hours per dayperforming 3D processing would be diverted fromreading additional clinical cases, which wouldhave generated added revenue, and the facilitymight need to hire additional radiologists to readexams. Likewise, if CT or MR technicians were to

perform 3D imaging between scans, it would slowdown scanner throughput, decreasing revenue.A dedicated staff for 3D imaging services can pro-vide an efficient and consistently processed setof 3D views. By having a dedicated 3D technolo-gist processing exams, it is also possible to cre-ate greater uniformity and consistency acrossexams, as opposed to having 3D images pro-duced by a variety of radiologists or technolo-gists who are not trained to produce a clinicallydetermined set of 3D imaging protocols.

Requirements for a Successful 3D Imaging ServiceSuccessful implementation of a 3D imaging serv-ice requires that clinical workflow, protocols,billing and staffing issues are established in away that enables routine clinical 3D imaging withrapid turnaround and consistent, high-quality,clinically-relevant post-processed images. The 3Dimaging services at our institutions work closelyon an ongoing basis with hospital billing andcompliance, coding and PACS to establish work-flow, and with the radiologists, referring clini-


•• continued on p.34

WHY 3-D BRINGS MORE BENEFITS

In conventional 2-D mammography, patholo-gies of interest are sometimes difficult to visu-alise due to the clutter of signals from objectsabove and below. This is because the signaldetected at a location on the film cassette or digital detector is dependent upon thetotal attenuation of all the tissues above thelocation.

Tomosynthesis is a 3-D method of imagingthat can reduce or eliminate the tissue over-lap effect.While holding the breast stationary,

images are acquired at a number of differentx-ray source angles. Objects at differentheights in the breast project differently in thedifferent projections. The final step in thetomosynthesis procedure is reconstructingthe data to generate images that enhanceobjects from a given height by appropriateshifting of the projections relative to oneanother.

PERFORMING THEACQUISITION

The geometry of tomosynthesis is shown inFigure 2.The breast is compressed in a stan-dard way.While holding the breast stationary,the x-ray tube is rotated over a limited angu-lar range.A series of low dose exposures aremade every few degrees, creating a series ofdigital images. Typically, the tube is rotatedabout ±15º, and 11 exposures are made every

3º during a total scan of 10 seconds.The indi-vidual images are projections through thebreast at different angles and these are whatare reconstructed into slices.

Normally the breast would be placed in theMLO or the CC view, although the tomosyn-thesis system should support the ability toacquire images in any desired orientation.There are two basic tomosynthesis systemdesigns, which differ in the motion of thedetector during acquisition. One methodmoves the detector in concert with the x-raytube, so as to maintain the shadow of thebreast on the detector.An alternate method isto keep the detector stationary relative to the


FULL FIELD BREAST TOMOSYNTHESISSignificant Benefits of 3-D Imaging

Andrew P. Smith, Ph.D.

What is Breast Tomosynthesis?Breast tomosynthesis is a 3-dimensional imaging technology that involves acquiring images of a stationary compressed breast

at multiple angles during a short scan. Individual images are then reconstructed into a series of thin high resolution slices that

can be displayed individually or in a dynamic ciné mode.

FULL F IELD BREAST TOMOSYNTHESIS

Fig. 1: Cross-sectional tomosynthe-sis slice from the centre of abreast shows a spiculated lesion

Fig. 2:Tomosynthesis acquisition geometry show-ing the direction of motion of the x-ray source,and the orientation of the reconstructed planes

Fig. 3:Tomosynthesis imaging can involve twoacquisition geometries: stationary and movingdetectors.

breast platform. Systems that utilise stationarydetectors will have a smaller field of view thansystems that move the detector, because onlya moving detector manages to keep the entirebreast tissue imaged at all angles.

OPTIMISING IMAGEACQUISITION INTOMOSYNTHESIS

Another consideration in the design oftomosynthesis systems is the motion of the x-ray source during acquisition. The x-ray tubecan move in a continuous or step-and-shootmotion. If the tube rotates continuously, shortx-ray pulses are used to avoid blurring theimage. If step-and-shoot motion is employed,the gantry must come to a complete stop ateach angular location before turning on the x-rays, otherwise vibration will blur the image.With continuous motion, scan speed must beslow enough, or each x-ray exposure shortenough, to avoid image blurring due to focalspot motion.

The angular range and number of exposuresacquired during the scan are additional vari-ables that need to be optimised. In general,more exposures will allow reconstructionswith fewer artifacts. This must be balancedagainst the fact that for a given total examina-tion dose, more exposures will mean smallersignals for each of the individual shots. For suf-ficiently small exposures, imager receptornoise will dominate the image and degradereconstructed image quality. With regards toangular range, a larger angular range givessuperior reconstructed slice separation,where smaller angular ranges keep morestructures in focus in a given slice. Increasedseparation might be desired for resolving twoclosely lying structures, but could impair theappreciation of a cluster of microcalcificationsby having individual calcifications appear in dif-ferent slices.

POTENTIAL CLINICALBENEFITS

Tomosynthesis should resolve many of the tis-sue overlap reading problems that are a majorsource of the need for recalls and additionalimaging in 2-D mammography exams. Thebiopsy rate should also decrease throughimproved visualisation of suspect objects.Some pathologies that are mammographicallyoccult will be discernable through the elimina-

tion of structure noise.Additionally, tomosyn-thesis may allow improved detection of can-cers in women with heterogeneously densebreasts.

Reduced DoseTomosynthesis may eliminate the need formultiple exposures of the same breast,because the images do not have tissue over-lap. Because of this, a single tomosynthesisacquisition, such as in the MLO orientation,may be all that is required. In addition, lessadditional imaging is required because of the

reduced recall rate.Thus it is entirely reason-able to assume that patient dose will end upless with tomosynthesis than with conven-tional mammography. Finally, the improvedcontrast of the tomosynthesis images mayallow lower dose while still maintaining clini-cal performance.

Tissue LocalisationBecause the location of a lesion in a tomosyn-thesis slice completely determines its true 3-

D coordinate within the breast, biopsy tissuesampling methods can easily be done usingthe tomosynthesis generated coordinates.

Faster Review TimeBecause the images are presented withreduced tissue overlap and structure noise,objects are expected to be visualised withimproved clarity.This will likely lead to fastercase review and more confident readings.

Reduced Compression PressureIn conventional mammography, breasts are



Fig. 3:Tomosynthesis imaging can involve two acquisition geometries:stationary and moving detectors.

Acknowledgments

Thanks to Dartmouth Hitchcock Medical Center, the University of

Iowa Health Care, and Robert D. Russo and Associates for supplying

the images shown here.

Andrew Smith, PhD, is manager of imaging science at Hologic, Inc. in

Bedford, Mass, where he is involved in research and development in

digital imaging systems. He attended the Massachusetts Institute of

Technology, where he received a bachelor and doctoral degrees in

physics.

To receive the complete version of this article, please contact

Managing Editor Dervla Sains at: [email protected]

highly compressed so as to reduce tissue overlap. High com-pression pressure is not needed for tomosynthesis imaging.Just enough breast compression to pull tissues out of the chestwall and keep motion at a minimum is adequate. Therefore,there is the possibility of less painful compression usingtomosynthesis. If reduced breast compression is used, the x-ray energies may need to be raised so as to more efficientlypenetrate the thicker breasts. In this case, it is important thatthe image receptor maintains its high quantum efficiency at thehigher energies. Cesium iodide, with poor absorption at high-er kV, may not be the optimal detector material. A selenium-based detector does not have this limitation as its k-edge isbelow the mammographic energy range.

Contrast Enhanced ImagingResearchers have studied mammography using IV administerediodinated contrast agents. Using either dual energy or pre- andpost-contrast imaging, they have observed enhancement ofotherwise occult cancers and differentiation of benign frommalignant tumors.While this research is still in its infancy, con-trast enhanced tomosynthesis images might offer even greatermalignant tumor to background uptake than observed with the2-D contrast imaging, and could conceivably supplant MRIgadolinium breast imaging.

CONCLUSIONS

Tomosynthesis offers the possibility of revolutionising mam-mography. In particular, tomosynthesis may offer the followingpotential benefits:�Elimination of overlapping tissues�Better cancer detection�Fewer recalls�Fewer biopsies�Less dose�Less painful compressions�Faster review


in the current organisational environment shouldbe considered:• What groups will support the development of a remote reporting service? Why? • What groups will block the development of the service? Why? • How will you gain support or buy-in for thedevelopment of the service in your organisation?• What problems can you anticipate that willaffect the success of the remote reporting service?

The remote reporting service provider should beclosely involved in the organisational changemanagement of the customer. The customershould get familiar with the ‘face’ of the serviceprovider. The backgrounds of the project leaderand the core project team and their ability to exe-cute the business case strategy should be clear-ly described. At the very least, the followingquestions should be answered:• What are the roles and responsibilities of the project leader and the project team? • Who are the key leaders, what is their experience with similar projects?• Does the project team have training or learn-ing needs to support the success of the pro-posed project?• Describe the function of outside supportingprofessional services, if any.• What are the reporting relationships betweenkey project team members?

Continuous FeedbackWhen buying a remote reporting service the cus-tomer wants proof of quality, known and accept-ed processes and protocols, transparency, possi-bilities for peer review and double-blind readingsfrom time to time. On the other hand, the serv-ice provider expects access to the relevant data,feedback on discrepancies and learning fromother specialists.

A prerequisite for a self-sustainable remote radi-ology business case includes feedback from bothradiologists and clinicians in building and main-

Thus far, remote reporting has been technicallyrestricted by point-to-point connections andmanual sending of patient information betweenparticipating organisations. However, regionalsolutions for RIS and PACS covering the wholecommunity have addressed this lack, providinghealthcare record summaries or index databasesthat are the glue enabling the viewing of imagesfrom other organisations, as well as electronicmarketplaces, where consultation services can bedelivered in a flexible way.

Financial and Technical AspectsFinancial and technical considerations typicallydominate the planning of a remote reportingservice. Common questions that are discussedcarefully on the side of the service providerinclude:• How many units of clinical service will needto be sold to cover costs? • How many units of clinical service will needto be sold to make a profit?• What are the resource requirements (funding,personnel costs, facilities, technical solutions, etc.)?• How does the cost of production balanceagainst projected revenues?

The challenge, however, is to provide trust andlearning over distance across departmental oreven national boundaries. It is also crucial tounderstand how the community will be affectedby the proposed service to ensure viability afterthe pilot phase and integration as a seamlesspart of the radiological operation of a hospital.

In the following section, three different aspectsimportant in building trust in remote reportingare discussed: organisational change issues, con-tinuous feedback and legal implications.

Organisational Change IssuesWhen the organisation is prepared for integratingremote reporting as part of the radiological oper-ation of a hospital, trust in the service itself canbe built. In order to do so, the following factors


AUTHORS

DR HANNA POHJONEN

ROSALIECO OY

ESPOO, FINLAND

HANNA.POHJONEN@

ROSALIECO.FI

PROF. HANS BLICKMAN

CHAIRMAN

DEPT. OF RADIOLOGY

UMC ST. RADBOUD

NIJMEGEN, THE NETHERLANDS

[email protected]

BUILDING TRUST IN REMOTE REPORTINGEnsuring a Viable Service

Today, the possibilities offered by the digital workplace, such as remote reporting and off-hour cover-age mean that virtual radiologists can offer imaging services in new and exciting ways. The challenge,however, is to provide trust over distance - across departmental or even national boundaries. In thisarticle, we discuss three major issues in building trust in remote reporting: organisational changeissues, continuous feedback and legal implications.



Features❚ ❚ ❚

taining trust in a remote reporting situationwhere the service provider is not in the samelocation and ensuring transparency in perform-ance and quality indicators. Users of the remotereporting service should be able to give digitalfeedback easily and in a user-friendly way.

At the same time learning is enabled by system-atic automation of feedback on different levelsbetween participants in the healthcare process.Constructive feedback creates a safe environmentfor individual self-improvement. Feedback soft-

ware should be easy to useand preferably desktop-inte-grated with the local RIS/PACS(see fig. 1).

Legal ImplicationsIn building a remote report-ing business case, youshould consider the mainissues that may arise fromthe need to manage personalinformation in a manner thattakes into consideration bothindividual sensitivities andthe need to provide health-care practitioners (and,

potentially, patients, administrators and others)with access to health records. In particular, youneed to demonstrate that you have understoodthe trust and security implications arising fromthe legal and clinical environment in which theremote reporting service is to operate.

The following issues should be discussed andagreed on between the service provider and thecustomer:

• How will patient information be stored,transmitted and used so that it is kept confi-dential and only shared with those individualswho have a legitimate need to see it? Will en-cryption and electronic signatures be needed?

How will patient consent be recorded and, ifnecessary, used to govern access to information?• How will all actions performed be associatedwith the individual who performed them? Whatmanual and automated facilities will be requiredto maintain and subsequently process anyaudit trail/security log etc.? • What processes will be used to address dis-aster recovery and business continuity?• Who will provide the service and who, ulti-mately, will be responsible for the care of thepatient – will clinical responsibility be shared,in fact, between several clinicians?• How much will the patient be told abouthow their information is used and how willtheir informed, voluntary consent be obtained?Who, under what circumstances, may act on be-half of the patient to grant or withhold consent?• What legislation governs the capture, storage,dissemination and destruction of information?Are there different legal considerations in dif-ferent relevant countries? What are the legalimplications if the information managementprocess fails to achieve the required or expect-ed Quality of Service as might be described interms of confidentiality, integrity (e.g. com-pleteness and correctness), and availability(e.g. timeliness) of information?• Will the service be offered locally, nationallyor internationally? If so will the radiologistsinvolved need to be qualified and insured topractice in another country? Will it be neces-sary for them to revalidate their qualificationsor take new ones?• If the service is to be provided online, howwill contracts be created and entered into andhow will payments be collected?

ConclusionBuilding trust in remote reporting is a complexand challenging task that should be carefullyconsidered from several points of view in orderto assure a self-sustainable remote reporting service.

cians, CT and MR scan departments to establishclinical 3D and scan protocols optimised for clin-ically useful 3D imaging.

Conclusion3D imaging in radiology has had a major clinicalimpact in the past decade in routine clinical prac-tice. However, there is a cost and a learning curve

involved in producing optimal clinical 3D imag-ing. The benefits of implementing 3D imagingservices can include improved confidence in diag-nosis and treatment/surgical planning, reducedcost and invasiveness of procedures, pre-surgicalplanning rather than exploratory surgery and ulti-mately less risk to the patient and improvedpatient care.

Fig. 1: An example of feedback software from eCare,

which can be desktop-integrated with any RIS/PACS.

continued from p.29••

ECRI’s focus is medical device technolo-gy, healthcare risk and quality manage-ment, and health technology assess-ment. It provides information servicesand technical assistance to more than5,000 hospitals, healthcare organiza-tions, ministries of health, government and planning agencies, voluntary sector organizations andaccrediting agencies worldwide. Its data-bases (over 30), publications, informa-tion services and technical assistanceservices set the standard for the health-care community.

All of ECRI’s products and services areavailable through the European Office,addressing the special requirements ofEurope and the UK. Utilising some of theworld’s largest health related databases,help, support and guidance can be givento our European clients at a local level.


Publication of all submitted data is not possible: for further information please contact ECRI or [email protected].

ECRI is a totally

independent non

profit research

agency desig-

nated as a Colla-

borating Centre of the World Health

Organization (WHO). Such organisations

are appointed to contribute to WHO’s

public health mission by providing spe-

cialised knowledge, expertise, and sup-

port in the health field to the WHO and its

member nations. ECRI is widely recog-

nised as one of the world’s leading inde-

pendent organisations committed to

advancing the quality of healthcare with

over 240 employees globally.

PICTURE ARCHIVING ANDCOMMUNICATIONS SYSTEMS (PACS)PRODUCT COMPARISON CHART

Footnotes to the Product Comparison Chart

1 These recommendations are the opinions of ECRI’s technology experts. ECRI assumes no liability for decisions made based on this data.

2 Also text/arrow annotations, multi-series synchronization, crosshair 3-D navigation, ratio, area, perimeter including freehandmeasurements, and CR and CT image processing.

3 Also cardiology & mammography.

4 Also decesead, discharge date, location, maiden name, name, medical service,medical record #, registration date, gender, VIP, encounter/person personnel relation, encounter/person type, encoun-terstatus, and financial class.

5 Also remote storage services; supports EMC Centera and enterprise, IBM enter-prise storage, and others with integrationassessment.

6 Also virtual colonoscopy.

7 Active-active cluster recommended.

ECRI1

PACS

Single server cluster

Hardware independent

Windows or UNIXWindows or UNIX128-bit SSLWindows or UNIXExperinced database company

Hardware independentUnlimited

RAID (SAN)UnlimitedYes

YesYesYesYesYesYesYesYesYesYesOrthopedics, cardiologyYesYes

Yes2

Name or MRN

Automatic based connectionbandwithIdentical to diagnostic workstation, except 3-DThumbnails

Yes

YesYes

YesYesYes

UPS standardEvery hour

YesYesYesYes

Year 4

Brokerless, bidirectionalYesYes

YesYesYesYesYes

MODEL

WHERE MARKETEDSYSTEM CONFIGURATION

Architecture

Hardware

OPERATING SYSTEMSImage serverWeb server

SecurityDatabase server

ManagementLONG-TERM STORAGE

MediaMax. Capacity, TB

ON-DEMAND STORAGEHardwareMax. Capacity, TBMultiple remote servers capable

DIAGNOSTIC WORKSTATIONIndependent log-inAdmin-controlled worklistAd hoc patient search capabilityAuto notification of prior examsPrior reports (without images)User-definable hanging protocolsSession interruption functionColor and greyscale displayKey image select3-D image processingSpecialist physician toolsIntegrated report dictationVoice recognition

WEB IMAGES ACCESSRadiologist-specific web appMax # monitors supported

TOOLSPatient search

Image compression

Image manipulation

Image selection

Auto remote software updatesIMAGE SHARING

Printing supportCD-ROM production

SYSTEM ADMIN GUI TOOLSPatient manageHardware manageAuto fail-over of critical comps.

BACK-UPPowerDbase frequency

AUTO DUPLICATION OF LONG-TERMArchiveRemote system monitoringAuto alert of system failureTest server

INTERFACESIHE conformance

RISElectronic patient recordReport dictationOther

DICOM 3.0Query/ retrieve SCPQuery/ retrieve SCUWorklist managementPerformed procedure stepDICOM JPEG2000

CONTACT

ECRI EUROPE

WELTECH CENTRE RIDGEWAY,

WELWYN GARDEN CITY,

HERTS AL7 2AA, UNITED

KINGDOM

[email protected]

WWW.ECRI.ORG.UK

H E ALTHC AR E PRO DUCT COM PAR ISON CHART

Visage PACS 4.0/4.2

Worldwide

Centralized server

HP/Compaq/Dell

Windows 2003 serverWindows 2003 server128-bit SSLWindows 2003 serverMicrosoft SQL server

HD-RAID/DVD Central Storage (RAID/TAPE…)Unlimited

RAID (DAS/SAN/NAS)UnlimitedFail-over-server-capable

YesYesYesYesYesYesYesYesYesYesOrthopedics, cardiologyNo (RIS functionality)No (RIS functionality)

Yes2

Elaborate filtering grid

2 independent levels adjustable

All, limited 3D functionality

Thumbnails, series overview

Yes

YesYes

Yes but limied to PACS-typical requirementsYesYes

UPSAdministrator definable

OptionalYesYesOptional

Brokerbased

Brokerless, URL based, bidirectionalVia URLNo (RIS Funtionality)Report storage and correcture

YesYesYesYesNo

Synapse

Worldwide

Scalable from single server to multi site clustersWindows compatible

Windows 2003Windows 2003, IIS128-bit SSLWindows 2003Oracle

Selectable to customer requirementsUnlimited

Any spinning disk technologyUnlimitedYes

YesYesYesYesYesYesYesYesYesWith 3rd partyAll tools available to all usersWith 3rd party3rd party integrated

Same for all users5

Name, MRN, census, Query by example (QBE)

Lossless, user selectacble lossy

Window /level, zoom, pan, magnify, cine,density value, ROI, angle/ruler measure2

Thumbnails, crosshair for across series indiff planesWorkstations Yes

YesWith 3rd party

YesYesYes

UPSDaily, configurable, permanent transactionlogging

OptionalYesOptionalYes

Year 4, selected profiles

Brokerless, bidirectional, HL7, Web interfaceYesYes

YesYesYesYesNo

Provision PACS

Worldwide

Unified PACS/RIS

IBM, Dell, HP, Sun, optional high availability cluster

Linux or SolarisLinux or Solaris128-bit SSLLinux AS, Solaris 8Oracle

SAN/NAS, DVD, HDD, tape libraryUnlimited

RAID (SAN/NAS)UnlimitedOptional

YesUser controlledYesYesYesYesYesYesYesYesOrthopedic, surgical templates, stitching3

OptionalOptional

Yes4 + 1 for RIS

Multiple aliases, any institution specificalias, client, age range, DOB, race4

JPEG 2000

Zoom, pan, invert, orientation, line measurements, window with/level, othersThumbnails and worklist

Yes

YesDICOM CD burner

YesYesOptional

YesSite configurable

YesYesYesOptional

Yes

Unified/brokerlessYesOptionalNot specified

YesYesYesYesYes

PHILIPS MEDICAL

syngo Dynamics

Worldwide

Client/server

Micron NetFrame 620/640 (entry level);HP/Compaq ML370 (large)

Windows Server 2003MS IIS (Win Server 2003)SSLWindows Server 2003Microsoft SQL

DVD, DLT, HSM, PACSUnlimited

SANUnlimitedNo

Yes and userYesYesYesYesYesYesYesNo NoYesNoNo

YesUnlimited

Name, MRN, user defined

Proprietary

Gamma correction

Multiple image formats

Yes

Paper, DICOMOptional

YesYesYes

Yes, UPS standardDaily

YesYesYesOptional

Yes. Evidence Creator profile for Echo and Vascular studiesBidirectionalBroker or interfaceNoNot specified

YesYesYesYesNo



Carestream 10 PACS

Worldwide

Centralised, distributed

Sun, Wintel

Sun Solaris, WindowsSun Solaris, Windows128-bit SSLSun Solaris, WindowsOracle

Spinning disk, DVD jukes, tape jukes5

Unlimited

RAID (SAN/NAS)UnlimitedOptional

YesAdministrator/userYesYesWith/without imagesYesYesYesYesYesOrthopedic templating, mammography6

OptionalOptional

Yes2

Any defined worklist field; worklist canselect DICOM fieldsUser selectable

All, except 3-D

Thumbnail, key images, series,study/image level searchesYes

YesOptional

YesYesOptional7

UPSUser defined

YesOptionalWIPOptional

Year 4

BrokerlessVia URL activationOptionalStds based for LDAP, DICOM, HL7, URL

YesYesOptionalYesYes

Medimage

Worldwide

Centralized server with backup server

VEPRO class 2b certified

Windows 2003Windows 2003128-bit SSLWindows 2003VEPRO

CD/DVD robotUnlimited

RAID-SAN3-256Yes

YesYesYesYesYesYesYesYesYesYesOptionalYesYes

Yes2

Patient demographics, DICOM worklist

User-selectable lossless, lossy

All

Thumbnails, text

Yes

YesYes

YesYesYes

UPSOnline

YesYesYesOptional

Yes

All major RIS via own PACS brokerFull implementationYesAny doc can be stored in archive

YesYesYesYesYes

ECRI1

PACS

Single server cluster

Hardware independent

Windows or UNIXWindows or UNIX128-bit SSLWindows or UNIXExperinced database company

Hardware independentUnlimited

RAID (SAN)UnlimitedYes

YesYesYesYesYesYesYesYesYesYesOrthopedics, cardiologyYesYes

Yes2

Name or MRN

Automatic based connectionbandwithIdentical to diagnostic workstation, except 3-DThumbnails

Yes

YesYes

YesYesYes

UPS standardEvery hour

YesYesYesYes

Year 4

Brokerless, bidirectionalYesYes

YesYesYesYesYes

MODEL

WHERE MARKETEDSYSTEM CONFIGURATION

Architecture

Hardware

OPERATING SYSTEMSImage serverWeb server

SecurityDatabase server

ManagementLONG-TERM STORAGE

MediaMax. Capacity, TB

ON-DEMAND STORAGEHardwareMax. Capacity, TBMultiple remote servers capable

DIAGNOSTIC WORKSTATIONIndependent log-inAdmin-controlled worklistAd hoc patient search capabilityAuto notification of prior examsPrior reports (without images)User-definable hanging protocolsSession interruption functionColor and greyscale displayKey image select3-D image processingSpecialist physician toolsIntegrated report dictationVoice recognition

WEB IMAGES ACCESSRadiologist-specific web appMax # monitors supported

TOOLSPatient search

Image compression

Image manipulation

Image selection

Auto remote software updatesIMAGE SHARING

Printing supportCD-ROM production

SYSTEM ADMIN GUI TOOLSPatient manageHardware manageAuto fail-over of critical comps.

BACK-UPPowerDbase frequency

AUTO DUPLICATION OF LONG-TERMArchiveRemote system monitoringAuto alert of system failureTest server

INTERFACESIHE conformance

RISElectronic patient recordReport dictationOther

DICOM 3.0Query/ retrieve SCPQuery/ retrieve SCUWorklist managementPerformed procedure stepDICOM JPEG2000

E R R AT U MDue to a technical fault beyond our control, some of the data in thelast edition’s Product Comparison Chart was incorrectly transmitted.Please find herewith the corrected version.

A N A L O G M A M M O G R A P H Y PRODUCT COMPARISON CHART

SSoopphhiiee P1

WorldwideYesYesConstant potential, high-frequency, 80 kHz, single20-35, increments of 1kV1-72042 small focus, 120 large focus; availablewith a tube that gives 35 mA with smallfocus and 110 mA with large focus0.1-6 broad focus, 0.1-9.9 fine focusSolid state with 3 independent sensorsmAs, kV P3

Rotating, oil and fan cooled300,00056,000Mo/ Mo, Mo/ Rh0.1 and 0.3

AutomaticYesYesMotorized

+180, -135, motorized, isocentric,adjustable speed60 (23.5) motorized, adjustable speed65Digital display of force, thickness, and angleYes

1,300Optional185 x 75 (73 x 30)0.5 mm Pb equivalent or 0.3 mmMotorized, user-adjustable degressivespeeds and force; conventional andTwincomp compression systems, automa-tic or manual release; digital display forbreast thickness and applied force; optio-nal MaxView breast positioning systemSelectable to 2009 user-selectable; 1 user-configurable for AEC5:1, 34 lines/ cm18 x 24 cm; 24 x 30 cm reciprocating1.3x to 1.8x, motorized and continuosly adjustable

Microprocessor-controlled Cytoguide/DigiGuideNetwork ID cameraOptional208-240 10% VAC; 50/60 Hz; 15A98.5 x 76 x 90 (38.8 x 29.9 x 35)160 (352)Cytoguide, DigiGuide, network ID camera,rectangular localization paddle with scaleand crosshair, high-lip compression pad-dle, MaxView breast positioning system,radiation protection screen, accessorystorage unit, CR interface, flex-AEC

Dual control panels; automatic Rh filterselection; fully automatic technique selec-tion based on tissue thickness and compo-sition; compact and transportable; auto-matic release; antiblooming (bias) circuit;automatic view angle; help-code display;built-in calibration and maintenance sys-tem; autoload Bucky. P4

NNuuaannccee CCllaassssiicc P1

WorldwideYesYesConstant potential, high-frequency, 80 kHz, single phase20-35, increments of 1kV1-72042 small focus, 120 large focus; availablewith a tube that gives 35 mA with smallfocus and 110 mA with large focus0.1-5 broad focus, 0.1-9.9 fine focusFlex-AEC with 48 detectorsmAs, kV P2

Rotating, oil and fan cooled300,00056,000Mo/ Mo, Mo/ Rh0.1 and 0.3



1,300Optional185 x 75 (73 x 30)0.5 mm Pb equivalent or 0.3 mmMotorized, user-adjustable degressivespeeds and force; manual compression,automatic or manual release of compres-sion; digital display for breast thicknessand applied force; optional MaxView breast positioning systemSelectable to 2009 user selectable; 1 user configurable for AEC

5:1, 34 lines/cm18 x 24 cm; 24 x 30 cm reciprocating1.6x, 1.8x, 2.0xMicroprocessor-controlled Nuance ClassicCytoguide/Nuance Classic DigiGuideNetwork ID cameraoptional208-240 10% VAC; 50/60 Hz; 15A103 x 76 x 100 (40.4 x 29.9 x 39.2)180 (396)MaxView breast positioning system, sideaccess positioning system, Nuance ClassicCytoguide/DigiGuide, network ID camera,perforated or rectangular localization paddle with scale and crosshair, high-lippaddle, accessory storage unit, shield,turnable base, CR interfaceDual control panels; automatic Rh filterselection; fully automatic technique selec-tion based on tissue thickness and composi-tion; compact and transportable; automaticrelease; antiblooming (bias) circuit; auto-matic view angle; help-code display; built-incalibration and maintenance system. P4

ECRI E1

AAnnaalloogg MMaammmmooggrraapphhyy

High-frequency, single-phase22-354-600Up to 100

0.02-8YeskV,mAs, anode/ filter

Rotating300,00060,000Mo/ Mo, Mo/ Rh0.1 and 0.3

YesYesYesElectromagnetic

-135 to +180

100 (39.4)66Distance and pressure

>800

Manual, automatic, fine adjustment

200All (unless digital)5:1For both film sizesYesOptional

YesOptional

MMOODDEELL

WHERE MARKETEDFDA CLEARANCECE MARK (MDD)GENERATOR TYPE

kV RANGEmAs RANGEmA range

Time range, secAEC DETECTORParameters controlled

X-RAY TUBEAnode type

Heat capacity, HUHeat dissipation rate, HU/ minTarget/ filter combinationsFocal spot size, mm

POSITIONING ASSEMBLYCollimation

18 x 24 cm24 x 30 cm

Movement locksAssembly movement

Rotation,

Vertical, cm (in)SID, cmScale guide

HANDSWITCH RADIATION OUTPUTmR/ sec @ 28 kVp

RADIATION SHIELDL x W, cm (in)Thickness

COMPRESSION SYSTEM

Force, newtonsSCREEN-FILM SYSTEMSGRID RATIOBUCKYMAGNIFICATION DEVICESTEREOTATIC DEVICE

FILM ID SYSTEMLABEL PRINTERPOWER REQUIREMENTSH x W x D, cm (in)WEIGHT, kg (lb)OPTIONAL ACESSOIRES

OTHER SPECIFICATIONS

Publication of all submitted data is not possible: for further information please contact ECRI or [email protected].

FOOTNOTES TO THE PRODUCT COMPARISON CHART

EECCRRII E1 These recommendations are the opinions of ECRI's technology experts. ECRI assumes no liability for decisions made based on this data.

PPllaannmmeedd P1 Marketed in Japan by Shimadzu Corporation. P2 User-selectable normal AEC (mAs) or advanced AEC (mAs, kV); kV and thickness compensated; flex-AEC

automatically selects sensors.P3 User-selectable normal AEC (mAs) or advanced AEC (mAs, kV); kV and thickness compensatedP4 Complies with IEC 60601-1, IEC 60601-2-45, IEC 60601-1-2 (EMC) and IEC 60601-2-28

(x-ray tube assemblies). Meets requirements of CSA, DHHS, and UL.P5 autoload Bucky with MaxView/MaxView-ready units.

HHoollooggiicc H1 Please note: The Affinity is CR compatible and meets European mammography requirements.

SSoopphhiiee CCllaassssiicc P1

WorldwideYesYesConstant potential, high-frequency, 80 kHz, single20-35, increments of 1kV1-72042 small focus, 120 large focus; availablewith a tube that gives 35 mA with smallfocus and 110 mA with large focus0.1-6 broad focus, 0.1-9.9 fine focusSolid state with 3 independent sensorsmAs, kV P3

Rotating, oil and fan cooled300,00056,000Mo/ Mo, Mo/ Al; optional Mo/ Rh0.1 and 0.3



1,300Optional185 x 75 (73 x 30)0.5 mm Pb equivalent or 0.3 mmMotorized, user-adjustable degressivespeeds and force; automatic or manualrelease of compression; digital display forbreast thickness and applied force; optional Twincomp or MaxView breastpositioning systemSelectable to 2009 user-selectable; 1 user-configurable for AEC5:1, 34 lines/ cm18 x 24 cm; 24 x 30 cm reciprocating1.6x, 1.8xMicroprocessor-controlled Cytoguide/DigiGuideDaylight ID system or network ID cameraOptional208-240 10% VAC; 50/60 Hz; 15A98.5 x 76 x 90 (38.8 x 29.9 x 35)160 (352)Cytoguide, DigiGuide, network ID camera,perforated or rectangular localization paddle with scale and crosshair, high-lippaddle, MaxView breast positioning sys-tem, Twincomp compression, radiationprotection screen, accessory storage unit,CR interface, flex-AEC

Dual control panels; automatic Rh filterselection; fully automatic technique selec-tion based on tissue thickness and compo-sition; compact and transportable; auto-matic release; antiblooming (bias) circuit;automatic view angle; help-code display;built-in calibration and maintenance system;P4, P5

PHILIPS MEDICAL

DDiiaammoonndd

Worldwide Yes Yes Single-phase, high-frequency, 3.6 kVA (2.5 kW)15-39, increments of 1 kV2-50030-100

0.02-10AutoPoint, 8 discrete detector arraysTime, kV, mA, filter, detector

Rotating, dual-angle300,00060,000Mo/ Mo, Mo/ Rh, Mo/ Al0.1 and 0.3

AutomaticNANAMotorized

185

77 (30)66Digital

Yes

≥840Yes194 x 81 (76 x 32)0.5 mm Pb equivalentMotorized, bidirectional ECS, SoftTouch manual

0-250NA5:1, ROC equivalent 6:118 x 24 cm; 24 x 30 cmMultiChoice single device 1.6x, 1.8x, 2xDelta 32

Dataflash PlusNA198-264 VAC; 50/60 Hz; 16A194 x 68 x 121 (76.5 x 27 x 48)350 (771)3-D imaging with TACT (tuned aperturecomp.tomography), specialty paddles

ParkBack tube head; AutoPoint automaticdetector selection; PaddleLogic; motorizedcassette loading. Meets requirements ofIEC 60601-1, ISO 9001, MQSA, and UL.

LLoorraadd AAffffiinniittyy SSeerriieess

WorldwideYesYesConstant potential, high-frequency, inverter20-39, increments of 1kV3-50010- 100

Up to 5Solid-stateAutomatic time/ kV/ filter

Mo, rotating300,00060,000Mo/ Mo, Mo/ Rh0.1 (small), 0.3 (large)

AutomaticAutomaticAutomaticElectromagnetic, fail-safe

+195, -155, digital readout

71-140 (28-55) motorized65Digital readout

No

≥800Yes185 x 60 (73 x 24)0.5 mm Pb equivalentManual, motorized in both directions; precompression, full compression; dualfootswitch

110-178 full compression, 300 manualUp to 3, programmableHTC or 5:1 linear, focused standard18 x 24 cm, 24 x 30 cm1.8xStereotactic compatible

Rapid ID FlasherOptional200-240 VAC 10%; 50/60 Hz; 25 A178 x 76 x 109 (70 x 30 x 43)

268 (588)HTC grid and FAST paddles (standard onplatinum models), various compressionpaddles, magnification table, localizationkit; 10 cm coned down, aperture, view, orintegrated markers

18 x 24 cm SRL 2000 ;Bucky; 24 x 30 cmSRL 2000 Bucky; HTC grids; FAST paddles,various paddles; magnification platform;full-field magnification; aperture; faceshield; radiation shield; Rapid ID Flasher;dual-function footswitch; auto aperture;integrated markers availableH1

LLoorraadd MM--IIVV SSeerriieess

WorldwideYesYesConstant potential, high-frequency, inverter20-39, increments of 1kV3-50010- 100

Up to 5Solid-stateAutomatic time/ kV/ filter

Mo, rotating300,00060,000Mo/ Mo, Mo/ Rh0.1 (small), 0.3 (large)

AutomaticAutomaticAutomaticElectromagnetic, fail-safe

+195, -150, digital readout

63.5-140 (25-55) motorized65Digital readout

No

>1,500, 60 cmYes190 x 80 (75 x 31)0.5 mm Pb equivalentManual, motorized in both directions; precompression, full compression, dual compression modes; dual ,footswitch

89-178 full compression, 300 manualUp to 3, programmableHTC or 5:1 linear, focused standard18 x 24 cm, 24 x 30 cm1.8xOptional StereoLoc II

Integrated AutoFilm IDOptional200-240 VAC 10%; 50/60 Hz; 35 A190 x 64 x 128 (75 x 25 x 50) gantry, 189 x 81 x 43384 (800) gantry, 91 (200) consoleHTC grid and FAST paddles (standard on platinum models), various compression paddles, StereoLoc II, DSM, localization kit, barcode reader, accessory cabinet, integrated markers, MIS interface

18 x 24 cm SRL 2000 Bucky; 24 x 30 cm SRL 2000 Bucky; HTC grids; FAST paddles, various paddles; magnification table; face shield; radiation shield; AutoFilm ID;dual-function footswitchPlease note: The M-IV is CR compatible and meets European mammographyrequirements.

Germany is probably unique in that it maintains two separate sys-

tems for providing medical imaging services. Although radiologists

and other medical specialists using medical imaging technologies

operate both in hospitals as well as in outpatient facilities, both

offices are subject to two different reimbursement systems. In addi-

tion, some medical imaging technologies may be used by non-radio-

logic specialists in Germany, for example, the use of diagnostic ultrasound

by a wide range of medical specialist professions. From the point of view

of providers of medical imaging equipment, this means that they have to

adjust to different groups of customers as well as different economic conditions.

Imaging Hit by Cost ControlIn the past five years, the German market formedical imaging equipment has been basicallystagnant, due to a number of cost containmentmeasures in the Statutory Health Insurance sys-tem, known by its German abbreviation “GKV”.Through a number of measures, reimbursementfor all medical procedures, including medicalimaging, has been controlled. At the same time,Germany introduced a DRG-based reimbursement

system in its hospitals. These influences andchanges have in the past years greatly reducedthe ability to invest in medical imaging technologies.

Lower Demand for Mid-range EquipmentThe German market for medical imaging equip-ment (excluding IT systems like RIS and PACS)has an average yearly value of around 725mEuro. At the top end of the market, modernequipment has replaced previous generations,thus improving the quality and efficiency of imag-ing services provided. At the lower end of themarket, modern production methods introducedby the industry have helped to make economicversions of imaging equipment widely available.Such systems tend to provide only a limited set

of features compared to the most advanced sys-tems. Depending on reimbursement details inGermany, there is a slight pull for high end qual-ity as well as for low end prices at the same time.Customers have increasingly revised their pro-curement practices to reflect this new economicenvironment. Increasingly, funds available forinvestment are distributed between high- andlow-range pieces of equipment, reducing themarket potential for mid-range equipment. Thefollowing paragraphs look at several segments ofthe market.

Market SegmentsMRI and CT, the current procedures of choice formost clinical situations, enjoy relativelyfavourable market conditions, although they aresubject to the general trends described above.Multi-slice CT as well as high-field MRI systemshave encouraged replacement decisions in orderto keep track of technological as well as medicaldevelopments.

Trend of Digitisation in ImagingIn Germany, x-ray as well as angiography modal-ities are open to use from non-radiologist med-ical specialists. However, this is under the condi-tion that the individuals in question haveacquired the necessary qualifications and the useof these imaging technologies falls within thescope of their specialty. Examples are cardiolo-gists as well as orthopaedic specialists, who both


THE MEDICAL IMAGING INDUSTRY IN GERMANY

Largest Single Imaging Market in Europe

AUTHOR

DR HANS-PETER BURSIG

MANAGING DIRECTOR

ZVEI DIVISION MEDICAL

ENGINEERING

FRANKFURT AM MAIN, GERMANY

[email protected]

❚❚

❚Countr

y F

ocu

s G

erm

any

2000 734m €

2001715m €

2002732m €

2003710m €

2004718m €

2005732m €

Market Values 2000-2005 Sum: Medical Imaging only

make use of medical imaging in questions spe-cific to their specialty. While the demand forangiography has benefited from advances ininterventional radiology, the demand for x-rayequipment has been declining. This is mainly dueto the economic situation of non-radiologic usersof such equipment.

Nevertheless, the introduction of digital x-raytechnologies (both CR and DR) has led to thereplacement of conventional systems. This isespecially the case in settings where most of theequipment used is already digital and feedinginformation into a departmental information sys-tem and a PACS. A specific situation also existsin the area of mammography. Germany is in theprocess of establishing a national mammographyscreening programme. The requirements for thisprogramme may lead to the replacement of a cer-tain number of existing pieces of equipment.

Some Technologies Still Lack AttentionThe market for nuclear medicine is subject to par-ticular conditions, since conventional nuclearmedicine has been restricted to specific proce-dures and cases due to advances in other imag-ing technologies. On the other hand, PET is pro-viding a powerful imaging technology, whose fullpotential is not yet fully understood. The devel-opment of hybrid systems (e.g. PET/CT) is furtherenlarging the scope for PET. The market is, nev-ertheless, held back by the fact that PET has notyet received approval for reimbursement from“GKV”, if performed outside hospitals. In total,the market for conventional nuclear medicinesystems has been stable, while limited growthhas been achieved in the market for PET systems.

High Quality of Equipment and EducationThe market for diagnostic ultrasound shows themost diverse picture. Used by most medical spe-cialists, ultrasound is the most widely-used tech-nology in Germany. This has led to the develop-ment of a large number of specific applicationsand technologies being available. Despite thatdegree of specialisation, the market has to a veryhigh degree been subject to the general trendsdescribed above. The number of pieces of equip-ment sold has increased, while the total value ofthe market has remained stable. At the sametime, the German Society for Ultrasound inMedicine (DEGUM) is concerned about the educa-tion of users of ultrasound in Germany and isproposing stronger criteria for training. Anotherconcern of DEGUM is that a considerable number

of pieces of equipment may be too old and arenot in a proper state of maintenance.

Improvements in WorkflowOf specific note is the market for IT systems inradiology, particularly Radiology InformationSystems (RIS) and Picture Archiving andCommunication Systems (PACS). This market inGermany is worth approximately 100m Euro peryear, although the award of large-scale projectsmay distort the picture in individual years. Theneed to improve efficiency and maintain diagnos-tic quality requires customers to analyse process-es within their departments and improve work-flow. As a consequence, customers increasinglyaim to integrate and upgrade existing IT systems.In this context, German customers are puttingconsiderable emphasis on the use of reliablestandards and open, practice-oriented interoper-ability requirements. For example, most calls fortender name compliance with DICOM and certainDICOM services as compulsory. In order to pro-mote the interoperability of IT solutions acrosstechnical borders and different providers, theGerman X-ray Society and ZVEI jointly supportthe Integrating the Health Care Enterprise (IHE)initiative in Germany. This initiative has foundstrong interest among radiologists in Germanyand is now being applied in other medicaldomains with considerable success.

Germany Remains an Attractive Imaging MarketThe German market is the single largest marketwithin Europe and capable of absorbing innova-tive medical imaging technologies. At the sametime, the high number of qualified users providesa powerful platform for the further developmentof medical imaging technologies. However, ZVEIestimates the investment backlog in Germanyfrom previous years to be between 5 to 7 billionEuro for medical imaging equipment alone.Based on this, there is considerable need for themodernisation of the existing infrastructure. The climate for investment began to improve in2005. There are indications that the adjustmentto the new economic and organisational condi-tions for medical imaging has been largely com-pleted. Customers are now increasingly lookingat investment in medical technologies as a wayto further improve the quality and efficiency oftheir departments. From a business perspectiveand despite its complex nature, the German mar-ket for medical imaging equipment thereforeremains highly attractive.

Country Focus Germany❚ ❚ ❚



Origins of the SocietyThe initiative for founding a national society ofradiology came from the ‘roentgenvereinigung’(community of radiologists) in Berlin, which wasat that time in existence for seven years.Roentgen’s findings created great enthusiasmand found wide acceptance among the medicalcommunity not only in Germany but also world-wide. Since 1896, radiology has already been anexciting science marked by the installation of a‘roentgen laboratory’ in the surgical departmentof the famous Charité hospital in Berlin. The planto invite ‘roentgenologists’ from all over theworld to participate in the 1st German Congresswas developed in Berlin and was embraced bythe radiologic community worldwide.

From Annual Congress to National SocietyThe initiators of the Congress decided thereforeto create a national society in order to organisean annual scientific meeting and thus to improvethe exchange of knowledge amongst its mem-bers. 180 participants applied onsite for member-ship. Since then, 87 German congresses of radi-ology have taken place.

As with other medical fields, specialisation inradiology led to offshoots which then becameindependent societies. The majority of our mem-bers are active in diagnostic and interventionalradiology. Close cooperation with radio-oncology,nuclear medicine and medical physics is a neces-sity that has additionally been cemented by writ-ten agreements.

MissionThe original ideas of the founding pioneers havenot changed during the last century. Our missionis still to encourage and support research in allfields of radiology, to offer a forum for nationaland international exchange of knowledge andexpertise, to support continuing radiological education, to foster the cooperation and inter-action with radiological subspecialties, as well as with the medical profession at large, and

to offer political institutions the know-how of our experts.

With specialisation and with the rapid develop-ment of new technologies, specialist groups havebeen founded within the framework of our socie-ty. Today more than twenty working groups, taskforces and commissions are supporting the Boardof Directors and promoting radiology whereverpossible.

Board of DirectorsThe board of directors is elected biannually. Itconsists of ten members and combines radiolo-gists from both university and public hospitals,as well as private practice. As well as myself, theVice-president is Prof. Dr Bernd Hamm fromBerlin and the President-elect is Prof. Dr MichaelLaniado from Dresden.

Continuing EducationIn 1998, our society founded an Academy ofContinuing Medical Education in Radiology whichbecame one of the most powerful tools to certi-fy and evaluate seminars and courses in radiolo-gy. Participants from all courses certified by theAcademy evaluate individual lectures by filling ina standardised questionnaire. The electronic eval-uation of the forms allows each lecturer to com-pare his results with the averaged results of alllectures within the programme of the Academy.This procedure, which has been adapted by anumber of other medical societies in Germany,led to an improvement of the didactic quality of

GERMAN RADIOLOGICAL SOCIETYProfile of the Deutsche Roentgengesellschaft (DRG)

On May 2, 2005, the Deutsche Roentgengesellschaft (DRG) celebrated its 100th anniversary. Founded

in 1905 in Berlin, its illustrious list of founding members includes Conrad Wilhelm Roentgen. Today,

the society has grown to include nearly 6,000 members.

AUTHOR

PROF. MAXIMILIAN REISER

PRESIDENT

GERMAN SOCIETY OF RADIOLOGY (DRG)

BERLIN, GERMANY

[email protected]

Country Focus Germany ❚ ❚ ❚

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TOSHIBA Medical Systems GmbH www.toshiba-medical.de

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the courses and the individual presentations.3,600 radiologists so far have become membersof this Academy.

The Congress TodayAs was the case from the very beginning, one ofthe core activities of the Deutsche Roentgen-gesellschaft is the organisation of the annualradiology congress in Berlin. It attracts about7,000 participants annually from Germany and itsneighbouring countries. With the introduction ofan ‘International Day’ where experts from abroadpresent state-of-the-art lectures on highly attrac-tive topics, the congress welcomes increasing

numbers of participants from colleagues of otherEuropean countries. During 2007, the central topics of the International Day will bemammography and prostate cancer.

The international lectures are presented inEnglish, whereas most of the other presentationsare in German. More than 1,000 abstracts aresubmitted annually. Abstracts are evaluated andrated by a reviewing board. The final selection isdone by the congress President and his team.Only 55% of submitted papers will be accepted.Since the last congress, all posters are presentedelectronically within the EPOS system.

We provide a wide range of radiology services,dispersed throughout different departments,including General and Interventional Radiology,Neuroradiology, Nuclear Medicine and PaediatricRadiology. For example, in the main department(General and Interventional Radiology), morethan 130,000 studies are performed each year,including 23,000 CT studies and 3,000 interven-tions. A wide variety of different multi-slice CTscanners are available, including a 64-row, 16-rowand 4-row scanner in the main department and a32-row scanner in Neuroradiology.

Current Information SystemAll departments are linked by one general infor-mation system (RIS), which has been in opera-tion since 1988. The RIS (Lorenzo RadCentre,iSoft) is used for patient data (ADT), scheduling,documentation, reporting, analysis and variousother tasks. Also, for analysis and benchmarkingwe have initiated a proprietary small ‘businesswarehouse’ application. At the present moment,speech recognition is under evaluation and willbecome part of the reporting process in order toimprove turnaround time. We also have an inter-face for the transmission of patient data, reportsor documentation within the administrative system.

Growing Uses for PACSAs one of the earliest users in Germany, our PACShas been operational (including ProVision,

Cerner, and Lumigo, ConVis) since 1996. As of2000, PACS is used as a general image manage-ment solution available for all departments of thehospital which acquire digital images, for exam-ple, cardiology, endoscopy and microscopy,among others. More than eighty modalities arenow connected within the PACS. The amount ofnew data is about 13TB per year, with ever-grow-ing numbers due to new techniques in CT, MRIand other new image sources. However, about50% of this data comes from CT alone.

The second most significant image source isultrasound, particularly with echocardiography,where cine-loops as DICOM multi-frame-objectsare part of the study. A hospital-wide image andreport distribution system is available, which isvery well integrated and heavily in use, withmore than 2,500 requests per day.

Open and Scalable PACSIn 1996, we began a new concept for an openand scalable PACS based on the relatively newDICOM standard, inaugurated in 1993/94. At thebeginning of our PACS activities, it was very oftencumbersome to connect new devices with thisnew information system, because of limitedknowledge by the vendors about interfacing withnew DICOM services. Over the years, this issue ofintegration has been dealt with. Today, connect-ing a new device is almost easy. ‘Integrating the

AUTHOR

DR PETER MILDENBERGER

SENIOR RADIOLOGIST


JOHANNES GUTENBERG

UNIVERSITY HOSPITAL

MAINZ, GERMANY

MILDEN@

RADIOLOGIE.KLINIK.UNI-MAINZ.DE

IT AND WORKFLOW ORGANISATIONInformation Technology in a University Radiology Department

The Johannes Gutenberg University Hospital is a fairly typical example of university

hospitals in Germany. It has about 1,500 beds, serving 55,000 inpatients per annum

as well as a large number of outpatients.


Country Focus Germany ❚ ❚ ❚

Health Enterprise’ (IHE) profiles and experiencehave proven very helpful for users, because ofthe standardised processes generated by them thathave created defined guidelines for interfacing.

In each new request for proposals we initiate, wenow ask for specific IHE profiles, even for modal-ities like CT or MRI as well as for information sys-tems. Today we use IHE profiles for ScheduledWorkflow (general workflow), Patient InformationReconciliation (updates between different IT sys-tems), ConsistentTime (for synchronisation ofsystem time in different computers) and PatientData Interchange (Generating DICOM-CDs). Otherprofiles like Key Image Note, Enterprise WideUser Authentification or Personal White Pages areunder evaluation or in implementation.

Teleradiology SolutionWe are currently engaged in developing tools foran independent and open teleradiology solution(www.tele-x-standard.de). This solution connectsthe different hospitals within the overlying uni-versity hospital structure, and is in use for radio-logical examinations in emergency situations,consultation or follow-up studies. Also, a verynew application is the transmission of cardiolog-ical studies from the cath lab to our heart sur-geons. The technical basics of the solution areencryption and signature, based on PGP (whichcould also be extended to s/mime), transmissionwith SSH or DICOM email. This approach has

been approved by a national initiative, support-ed by the Geman Society for Radiology (DRG).Professional support is also available from differ-ent companies such as Aviconet. Medical imageprocessing is another important topic, becausenew CT and MRI studies allow quantification andfunctional analysis, e.g. tumour measurements,growing factors, heart function and tumour activ-ity. We are active in this area with our ownexperts and also a member of a related nationalresearch group, VICORA (www.vicora.de).

IT in EducationOne of our most significant activities focuses onpromoting IT in education, not only for studentsbut for physicians, too. Basic training experiencessuch as implementing a learning platform andbuilding a case collection are becoming more andmore important.

Internal OrganisationBecause of so many different acitivities in IT, wehave our own experts, a group of four people, aspart of the staff in the radiology departmentresponsable for RIS, PACS, teleradiology, hard-ware and so on. This underpins a strong cooper-ation with the central IT department, which isproviding the network or internet access.Radiologic IT staff are also supported by variousdevelopers for teleradiology, eLearning or imageprocessing solutions.

Foundation Studies in MedicineAlready during the foundation studies in medi-cine, several general lessons make studentsfamiliar with the physics and methodologies ofradiology, coupled with exercises to show themost important exams and their signs for select-ed diseases. In former times, these lessons wereguided by an experienced radiologist and imageswere adapted to the lessons’ topics. SomeGerman universities have now launched a new

course of study, where quite early (i.e. in the 3rdsemester of the study) students are taught radi-ology during courses in anatomy and clinical dis-ciplines beside the intrinsic information of thatdiscipline.

In addition, there are courses to make studentsaware of radiation protection methods. Duringthe last year of study, four months can be spentin a radiology department of a teaching hospital

The Experience in Germany

EDUCATION AND TRAINING FOR RADIOLOGY

To become a radiologist in Germany, several important educational steps must be taken during

and after completion of the study of medicine. Knowledge acquisition ranges from basic information

during medical study, to practical education in a hospital and finally, to continuing education and

special courses after board certification to become a radiological specialist.AUTHOR

PROF. DR BERTHOLD B. WEIN

ASSOCIATE PROFESSOR OF THE


MEDICAL CENTRE OF THE

TECHNICAL UNIVERSITY OF

AACHEN AND PRIVATE PRACTICE

RADIOLOGIST,

GEMEINSCHAFTSPRAXIS IM

KAPUZINERKARREE, AACHEN

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where live practice may be experienced by thestudent shortly before passing the medical stateexamination. In some clinical environments, firstexperiences are also made with interpreting radi-ological images. Having passed the medical stateexam, basic knowledge has been acquired aboutradiology and its methodologies.

Residentship: Achieving Board CertificationTo achieve board certification as a radiologist,interested physicians must enter a five-yearassistantship, mainly performed in a hospitalenvironment but to a limited extent also in a pri-vate teaching practice. A one-year assistantship ina clinical discipline is also accepted as a trainingperiod. During this time, certain obligations mustbe fulfilled by the resident, including self-per-formed exams monitored by an experienced radi-ologist. With an attestation of his period of edu-cation and exams performed, he can apply forboard certification which obligates him to pass a30-minute exam conducted by the Board. Thiscertification permits performance of exams underhis own responsibility. Federal Medical Asso-ciations are liable for those curricula and exams,which differ for every federal state in Germanyand may have different rules for the certificationprocess. However, recent homogenisation effortsare being undertaken to end up with nearly equaleducation regulations for all federal states allover Germany.

Continuing Medical EducationThe next step is to apply for a hospital workingplace or for work in the medical supply system inthe compulsory health insurance (CHI) system,which increases familiarity with more complexexams or facilitates specialisation in specific subdomains such as neuroradiology or paedi-atric radiology, for an additional period of two tothree years.

At the end of that period there will be anotherboard certification that testifies knowledge in therespective subdomain. If the decision is to enterthe CHI services, quality assurance measuresexist to ask members in the CHI medical supplysystem to prove continuing medical education(CME) by courses and visits to specialised cen-tres. The CME is assessed by national medicalassociations via credit points of which 50 peryear must be collected. There are some detailed

differences between distinct courses, but in gen-eral, one point equals one hour of certified andmonitored education in a medical topic. Approvalis given by the medical associations and theyoversee the courses. Normally those courses arepaid by participants and no reimbursement is given.

Quality Control in MammographyMammography is one specific field where radiol-ogists must show continuing quality and educa-tion. In curative mammography, every two yearsthe radiologist must sit an exam where casesfrom a mammographic database have to besolved. The exam is conducted by the CHI, supported by the Cooperative Initiative forMammographic Screening, Germany. Also over-seen by the CHI is the quality of mammographiesand reports, surveyed by dedicated medical col-leagues, assessing images and reports on a ran-dom basis from year to year for each associationmember. Both exams stimulate radiologists tokeep a high level of quality. In screening mam-mography even higher efforts for quality are laidout, including thorough examinations of readingradiologists on a yearly basis, as well as extend-ed observation and supervision of the decisionsof those reading radiologists. If the level of qual-ity is lower than a fixed margin, additional cours-es and teaching materials are implemented.

ConclusionBecoming a radiologist in Germany is, for morethan 6,000 radiologists, a certified and continu-ously supervised task. Thorough educationalcourses allow a continuing medical educationand guarantee a high level of skills and knowledge.


Medical StudyBasics in Radiology

Postgraduate EducationSpecial Knowledge in Radiology

Continuing Medical EducationSeveral Special Knowledges in Radiology

State Examination

Board Certification byMedical Association

Surveillance byMedical AssociationsandAssociations of CHIPhysicians

5-6

year

s5-

8 ye

ars

lifel

ong

Education of Radiologists in Germany

What are the Requirements?To effectively manage an organisation ofthis size and complexity requires you tomanage other managers, and to developstrategies for organisational success. Theresponsibilities of the clinical departmentadministrator are to not only support theChairman, but generally to ensure thedepartment is adequately staffed, financial-ly sound and delivers high-quality care in acost-effective manner. Typical areas ofresponsibility include:

• Financial management • Information Technology• Human Resource management • Billing & collections• Technical patient care services• Patient care clerical support • Nursing• Equipment• Regulatory

Need for Sound AdministrationAnother aspect of this type of organisa-tion is that physicians are organised sep-arately from the hospital and are also fac-ulty in the med school. Since they billpatients for the services they provide,professional managers are needed tooversee and manage this financial aspectof their activities. Further, since researchis also emphasised, with significantamounts of funding, managing the finan-cial aspects of grants is also needed.Because of this, radiologists also usuallyhave a full time manager, reporting to theradiologist Chairman, to manage theirbilling/collection activities as well as theresearch grant finances.

Rules and GuidelinesTo effectively manage employees andprocesses one needs sets of rules andguidelines to promote consistent action.Too many rules choke innovation and sti-fle creativity – too few promote chaos andvariability in quality and action. Findingthe right balance is critical. We developedmany departmental policies to guide theactions of both staff and supervisors.Generally, these policies were about howthe department should take care ofemployees and patients:

• Employee related: e.g., timekeepingrules, conduct, dress code, leave poli-cies, disciplinary actions, hiring require-ments, etc.• Technical and quality: e.g., exam pro-tocols, patient exam restrictions, imagequality standards, certification require-ments, radiation safety, etc.

We had both physician and a technologistQuality Assurance (QA) committees todevelop and approve technical policies.Employee policies were developed by thedepartment Senior Administrative commit-tee as well as by both the HR and financedepartment of the school and hospital.

Potential Staff ProblemsIn common with most institutions, poten-tial problems faced by radiologic staff fallinto four general categories:

1. Poor supervisors treating them incon-sistently and unevenly2. Poor equipment3. Poor environment4. Workload exceeding staffing levels

AUTHOR

HARRY GRANITO

CHIEF OPERATING OFFICER

ROSS SCHOOL OF BUSINESS

UNIVERSITY OF MICHIGAN

MICHIGAN, UNITED STATES

[email protected]

The first three problems, unaddressed,negatively influence staff recruitment andturnover which creates a larger problem(#4) as staff vacancies increase. Mydepartment and hospital were profitablewhich greatly reduced problems 2 and 3,and we focused much attention, effortand resources to educate and improve oursupervisors and managers. We believethat this singular strategy provides morepositive, cost-effective returns than anyother. Our department requires over 125technologists and our needs increaseevery year consistent with our growth inexams requested. Our primary focustherefore is on tech (and all employee)retention and good supervisors are thebest way to achieve high employee reten-tion. The added benefit is that when techsdon’t want to leave your department,other techs want to join this ‘good thing’and recruitment becomes easier.

Turf BattlesProviding great levels of service is a goodway to eliminate potential turf battles, as itnegates the argument that, since you can’tprovide the service at the level anotherdepartment needs for its patients, they willdo it themselves. Our principle strategywas to develop a joint operational pro-gramme whereby faculty physicians fromboth departments would use the hospitalradiology department and staff to providethe services. From the tech’s point of view,they were providing services to doctors of multiple departments for the samepatients and the impact was minimal. Thestress, however, was felt by the radiolo-gist who now had to share turf.

HOW TO. . .

MANAGE EMPLOYEES IN A RADIOLOGY DEPARTMENTPART ONE OF A T WO-PART S E R I E S E XPLO R I NG E M PLOYE EMA NAG E M E NT STRATEG I E S I N RADIOLO GY DE PARTM E NTSRadiology departments, due to their size and complex patient care processes usually havea full-time administrator to oversee these activities. In my former position as administrativemanager of the radiologist group at the University of Michigan medical school, a depart-ment that performs over 500,000 procedures per year in two main hospitals and six satel-lite locations in a two-county area, it was essential that each potential area of conflict wastightly controlled by policies and procedures.


�How To... �


�


What is IHE Europe and what are its aims?� IHE is a non-profit organisation spon-sored by professional bodies andhealthcare suppliers that gathers usersand vendors to address the problems ofhealthcare systems’ interoperability. Webelieve that interoperability should bebuilt around a core of common require-ments, taking differences between EUMember States into account, butenabling manufacturers to market theirproducts at both European and evenglobal level with only minor variations.

IHE in Europe organises activities toachieve the interoperability of existingproducts and facilitate the developmentof new interoperable products. Some ofthese activities consist of:

• Development of workflow descrip-tions and associated integration pro-files based on user requirements; • Organisation of live interoperabilitytesting between vendors (connect-a-thon), and of live interoperabilitydemonstrations at the European level;• Support to national IHE activities inorder to incorporate national require-ments into interoperability require-ments; and• Promotion of products that imple-ment IHE Integration Profiles througheducational activities, success stories,integration statements, etc.

What are IHE Technical Frame-works?� The IHE Technical Frameworks, avail-able for download, are a resource forusers, developers and implementers ofhealthcare imaging and information sys-tems. They define specific implementa-tions of established standards toachieve effective systems integration,facilitate appropriate sharing of medicalinformation and support optimal patientcare. They are expanded annually, aftera period of public review, and main-tained regularly by the IHE TechnicalCommittees through the identification

and correction of errata.There is an IHE Technical Framework foreach of the IHE domains. Volume I pro-vides a high-level view of IHE function-ality, showing the transactions organisedinto functional units called IntegrationProfiles that highlight their capacity toaddress specific clinical needs. Volume IIprovides detailed technical descriptionsof the IHE transaction used in thedomain.

How is an IHE IntegrationStatement developed? � IHE Integration Statements are docu-ments prepared and published by ven-dors to describe the conformance oftheir products with the IHE TechnicalFramework. They identify the specificIHE capabilities a given product sup-ports in terms of IHE actors and integra-tion profiles. Users familiar with these concepts canuse Integration Statements to determinewhat level of integration a vendorasserts a product supports with comple-mentary systems and what clinical andoperational benefits such integrationmight provide. Integration Statementsare intended to be used in conjunctionwith statements of conformance to spe-cific standards (e.g. HL7, IETF, DICOM,W3C, etc.).There is no requirement for a vendor toparticipate in an IHE Connectathon inorder to be able to publish an integra-tion statement. IHE integration state-ments help users by comparing productsfunctionalities.

What are some of IHE’s biggest successes in Europe? � I guess the biggest success of IHE inEurope is to have successfully devel-oped IHE in Europe. IHE started in theUS! IHE Europe was successful in import-ing the initiative, but more than that, inadapting it to the European context. IHEEurope is now contributing on an inter-national level and is, in a way, forcingIHE to become more international in its focus.

INTERVIEWEE

PROF. ERIC POISEAU

IT MANAGER

INTEGRATING THE HEALTHCARE

ENTERPRISE (IHE) EUROPE

UNIVERSITY OF RENNES

RENNES, FRANCE

IHE Europe is contributing at an interna-tional level with:

• Laboratory profiles; • IT-infrastructure XDS and PIX pro-files; and• Radiology PDI profiles, which foundtheir origins in Europe.

What integration challenges doyou think healthcare IT managersin Europe should be most con-cerned about? In my opinion, access to information,document sharing and security are thebiggest challenges facing healthcare ITmanagers in Europe. Healthcare informa-tion systems will more and more needto interoperate to exchange documents,images, patient identifiers, exchangeabout user rights.

Software applications are also more fre-quently required to interact with:

• Audit trails: sharing of logs, securityrequirements to centralise logs; • User rights: authentication, authori-sation... rights that may depend onthe role and the context; and• Patient identification: documentsharing requires sharing of identification.

INTERVIEW WITH

PROF. ERIC POISEAU

My Opinion�


Agenda

Key Seminars & Conferences

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MARCH 2007

9 – 13 EUROPEAN CONGRESS OF RADIOLOGYVIENNA, AUSTRIAwww.ecr.org

15 – 20 32ND ANNUAL SOCIETY OF INTERVENTIONAL RADIOLOGY (SIR) MEETINGWASHINGTON DC, UNITED STATESwww.sirweb.org

19 – 21 BRITISH NUCLEAR MEDICINESOCIETY SPRING MEETING 2007MANCHESTER, UNITED KINGDOMwww.bnms.org.uk

APRIL 2007

25 – 28 55TH ANNUAL MEETING OFTHE ASSOCIATION OF UNIVERSITY RADIOLOGISTSDENVER, COLORADO, UNITED STATESwww.aur.org

MAY 2007

16 – 19 GERMAN RADIOLOGY CONGRESS ANNUAL MEETINGBERLIN, GERMANYwww.roentgenkongress.de

JUNE 2007

11 – 13 UK RADIOLOGICAL CONGRESS 2007BIRMINGHAM, UNITED KINGDOMwww.ukrc.org.uk

12 – 15 EUROPEAN SOCIETY OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY (ESGAR)LISBON, PORTUGALwww.esgar.org

20 – 23 JOINT EUROPACS AND CARS CONGRESSBERLIN, GERMANYwww.europacs.org

27 – 30 CARS 2007 ANNUAL CONGRESSBERLIN, GERMANYwww.cars-int.org

NOVEMBER 2006

5 – 9 48TH ANNUAL MEETING OF THE AMERICAN SOCIETY FOR THERAPEUTIC RADIOLOGY & ONCOLOGY (ASTRO)PHILADELPHIA, PENNS., UNITED STATESwww.astro.org

9 – 11 46TH ANNUAL MEETING OF THE JAPANESE SOCIETY OF NUCLEAR MEDICINEKAGOSHIMA, JAPAN

www.jsnm.org

14 – 18 MEDICADÜSSELDORF, GERMANYwww.medica.de

26 – 1 92ND RADIOLOGICAL SOCIETY OF NORTH AMERICA (RSNA) SCIENTIFIC ASSEMBLY AND ANNUAL MEETINGCHICAGO, UNITED STATESwww.rsna.org

DECEMBER 2006

14 – 15 5TH ADVANCED ANEURYSM TREATMENT SYMPOSIUMOXFORD, UNITED KINGDOMhttp://www.medsci.ox.ac.uk/radiology/mscin/aats

JANUARY 2007

25 – 26 12TH EUROPEAN SYMPOSIUM ON ULTRASOUND CONTRASTIMAGINGROTTERDAM, THE NETHERLANDS

http://www2.eur.nl/fgg/thorax/contrast

FEBRUARY 2007

1 – 3 MR 2007: 12TH INTERNATIONALMRI SYMPOSIUMGARMISCH-PARTENKIRCHEN, GERMANYwww.mr2007.org

25 – 1 HEALTHCARE INFORMATION AND MANAGEMENT SYSTEMS SOCIETY ANNUAL MEETINGNEW ORLEANS, UNITED STATESwww.himss07.org