Detailed and Precise Measurement with Lesion Management

Larry Ray

Larry Ray, CTO R+I Volume Image Processing, Carestream Health

Precise lesion measurement is important for reliable evaluation of metastatic disease and faster assessment of the patient response to cancer treatment. For radiologists and oncologists, simple quantitative comparisons of historical exams – especially those imported from disparate PACS or modalities – have been a challenge in a traditional PACS, causing many to turn to costly dedicated workstations. Lesion Management is an embedded application tool in our Vue PACS that provides native oncology follow-up capabilities. The precision of the tool can help provide physicians with clearer and more detailed imaging exam results in less time, enhancing their productivity and efficiency to make a diagnosis.

There are several reasons oncology follow-ups are one of the most time consuming and challenging tasks for radiologists:

  • Relevant priors may not have been acquired by the same modality, thus making it difficult to compare as most PACS cannot correlate with different exam types
  • Identification, localization and measurements of lesions are often manual, time consuming and inconsistent
  • Often times lesion management and tracking is performed on a separate workstation or application, without integration to PACS

The lesion tool reduces the need for visual measurement by providing semi-automatic tracking and segmentation of lesions, which can help provide a faster and more consistent means of determining the size and estimating the overall volume of the lesion. The result has the potential to provide a better gauge of disease progression. Typically, when a radiologist first gets a case they mark the lesion and report on it before the data is stored. At a follow-up visit a second set of images with added lesions is read, often by a different radiologist. The lesion management software matches between the two reports and immediately generates a spreadsheet of the patient’s information. The data can be viewed and evaluated on a single exam basis, or a per lesion basis for comparison purposes.


When a patient is diagnosed with cancer it’s really a team effort between them and their care providers to choose the best possible treatment plan. Today, we have access to information almost immediately; questions get responses pretty quickly; we have better tools to fight these diseases. The lesion application is one of those tools. It allows for clearer, more meaningful communication and collaboration between radiologists, oncologists and referring physicians which is a vital step in providing the patient with the best care possible.

Editor’s Note:  The Lesion Management application, created by Larry Ray, Edward Gindele & Rick Simon, was a finalists for the Digital Rochester Great Awards in the Optic, Photonics and Imaging Technology category.

Learn more about Carestream’s Lesion Management application:

NYMIIS: Medical Imaging and Meaningful Use – It is No Longer an Option

Rich Pulvino, Digital Media Specialist, Carestream

Rich Pulvino, Digital Media Specialist, Carestream

With the creation of RIS, PACS and speech recognition, radiology once led the technology revolution in the healthcare industry. Unfortunately, now it is a sector of that industry that has fallen behind, on account of it lagging in the adoption of Meaningful Use (MU) criteria. But just because radiology is behind does not mean adoption is impossible.

This was the discussion presented by Dr. Keith Dreyer at New York Medical Imaging Informatics Symposium (NYMIIS) in New York City on September 16. In fact, MU adoption is picking up in the industry, but not as fast as the rates among physicians and hospitals. The numbers say that as of 2013, about 14% of radiologists are involved in the MU stages, while 50% of physicians are participating. Dr. Dreyer explained that this gap exists because of the silos and compartmentalization that exists between radiology practices and other departments in health facilities. RIS/PACS currently function separately from the EHR, and while progress is being made is alleviating this issue, there is still much to be done.

Ordering, scheduling and communication between physicians and patients are improving, but there remains a vital need for workflow and interpretation of studies. Between the information housed in the RIS/PACS and the EHRs, this is essentially two programs doing practically the same thing in terms of the information stored. Convergence is necessary if workflow and interpretation are to be improved.

Dr. Dreyer explained the fact that only 14% of radiologists are involved in MU is troubling considering that 90% of radiologists are eligible for the incentives. But the growth is promising—while 450 radiologists participated in MU in 2011, that number increased by 3,500 in 2012, and is predicted to increase by 6,000 in 2013, and by 8,000 more in 2014. Growth is occurring, but radiology is still going to be playing catch-up to the rest of the healthcare sector.

To provide guidance, Dr. Dreyer outlined a 10 step plan to help radiologists work their way through MU:

  1. Understand the MU program—the deadlines and responsibilities.
  2. Understand your organization’s plan for MU of eligible professionals (EPs)
  3. Gain institutional acceptance for participation in the organization’s MU/EP plan
  4. Understand and identify the certified EHR technology (CERHT) to be used for compliance
  5. Determine MU measures that are available and required in your practice
  6. Decree MU policies for activities, interpreting the regulations specific to your radiology practice
  7. Create a comprehensive set of MU compliance documents
  8. Review compliance documents with institutional stakeholders (CMIO, CIO, etc.)
  9. Review MU compliance documents among radiology staff
  10. Implement the strategies early with the appropriate dashboard to measure successes

Following the run-through of these 10 steps, Dr. Dreyer then went on to provide advice for radiology departments of different sizes—small practice/imaging center, medium practice/single hospital and large practice/multi-hospital system/imaging centers. The larger practices are the ones more likely involved in MU because these are the organizations that either already installed their own CEHRT or are able to access the health system’s CEHRT. Because of this, Dr. Dreyer went into more detail about the two smaller categories.

With the small practices and imaging centers, Dr. Dreyer recommended investigating the technology that is common across all centers similar to this size. This should provide some essential background information on the most appropriate solutions to implement. Based on the research collected, he said that it is possible for smaller practices to install a stand along CEHRT solution.

For the single hospital and medium practices, he recommended using existing CEHRT for program compliance. These smaller practices should convince hospital leadership to expand their MU program to include radiologists, since it is most likely focused only on physician EHRs. Much of the data entry will be performed by others, which makes it difficult to take advantage of special exclusions, and may require a pack for use of the technology.

To wrap up his talk, Dr. Dreyer reiterated how MU is marking a new era for radiology. He said that once that complete execution could help and hurt some depending on financial costs and ability to properly maintain the data. Overall, there is no denying that imaging health records are beginning to play a great role in the healthcare space. So much so that we are now beginning to see patients access their images, which is not required until MU stage 3. The MU pace of adoption is speeding up, and radiology cannot afford to be fall behind any further than it already is.

User Groups: An Important Component of Innovation and Customer-Vendor Relationships

Finn Mathiesen, CMIO, MD Administration and  Department of Radiology  Vejle Hospital - a part of  Hospital Group Lillebaelt

Finn Mathiesen, CMIO, MD,
Administration and
Department of Radiology
Vejle Hospital – a part of
Hospital Group Lillebaelt

User groups have been an important part of my career in health IT. I work for a county hospital group that consists of five hospitals and about 1000 beds, which conducts about 400,000 medical imaging exams per year throughout the entire group. As a frequent user and administrator of these technologies, I need to be in the know of not only what updates are coming from the vendors I work with, but also how other customers are using the technologies.  The culmination of these relationships between customer-vendor, and customer-customer, happens at user group meetings where the event turns into a hive of people looking not only to improve the product/service, but to learn from one another as well.

Throughout my time as a member of users groups and attending these events, I think there are two major advantages a customer can gain from participating, which I will address throughout the remainder of this post:

Collaboration: Working with other customers and the vendor(s) to develop new features/applications/products that address the customers’ needs

As an example, I have been using Carestream’s RIS for quite some time now. The tools needed in RIS must provide the user with fast functionality and provide the appropriate features for booking, scheduling, reporting, etc. and these need to be accomplished in very few clicks—this is information that must be accessible right away.

User group meetings are important for me as a RIS administrator because I can have a hand in influencing product developments to make sure that they are going in the right direction. What we see are that the meetings come up with suggestions that people want in their programs and not necessarily the same functions that all the regions want.

There is one important caveat that must be addressed among the users: there is always going to be a wide spectrum of needs that will be addressed and it is next to impossible to please every member in such a diverse group.  Users from different countries will have various needs, and these will differ among organizations. Be it hospital, or small practice, or between public health systems and private hospitals, needs and development of programs will differ and not all issues can be solved.

Because of this, prioritization is a must at user group meetings. I have experienced such meetings where input was given, but nothing came to light. Situations such as this make it vital for attendees (both users and vendors) to sum up the major requests that everyone can agree on. Customers are never going to be happy if there is the collection of ideas, and then those are brought to development, but then the customers never hear about the ideas again. Questions start coming to mind: Are we going to have our requests fulfilled? When can we expect the updates? Are the vendors listening?

I can attest that users have the perspective that there is a path to development and we must coordinate our expectations to the vendor’s road-map for product and services. This makes it common practice to create a group statement from users about which features are needed the most. For example, by the end of the user group meeting, stating, “These are the five functions that are most important to us.”

As users, we believe that all of our requests and needs are equally important, but priority needs to be established, or else no plans will be put into action. At a meeting, user must get a consensus for programmers and get different options. For example: “Does everyone need this feature, or just the guys in NY?”

Networking: Meeting and speaking with other customers can allow one to learn features/processes that perhaps were not known before. Additionally, it is always good to meet others who have experienced similar situations so that collaboration can be more efficient and fulfilling.

Connecting with users from other Scandinavian countries allows me to learn valuable ideas, set ups, and ultimately learn from one another. We invite each other to look at set ups and see how things are done differently. For example, at the last user meeting in Sweden, I learned about functionalities from system administrators based in Danish Sealand Region that used some fancy tricks that we could use in our system. They taught us a work around that we haven’t thought about before. We met them, talked to each other, and learned a valuable new lesson. This is one of the most important benefits from networking at user group meetings.

When it comes to user group meetings it is clear that there are many positives that can come out not just being in attendance, but also making sure that users remain active in the user group through the remainder of the year. Face-to-face communication is always the best, but beginning and extending conversations online in the actual user group has the ability to make these events even more beneficial.

PACS and the evolving UK Healthcare System

Dr. Stephen Davies, Consultant Radiologist,  Cwm Taf Health Board, and Medical Director, Medica Reporting

Dr. Stephen Davies, Consultant Radiologist, Cwm Taf Health Board, and Medical Director, Medica Reporting

The UK healthcare system is in a period of change and sustained pressure to meet demand within a tight fiscal regime. Never before has innovation in service delivery been more needed.

The UK National Health Service (NHS) was founded in 1948 with the guiding principles of a universal access for all UK citizens and healthcare which was free at the point of access. It was and is cradle to grave system of ‘social healthcare’ for all.

This has served the UK well but is under threat like many healthcare systems. There are two main drivers of change in the UK:

  1. Austerity measures as a result of the global recession
  2. An aging population and advances in medical knowledge, treatment and technology.

The political landscape has changed as well. The UK government has introduced an Act of Parliament to reform the commissioning of healthcare. This will open up the market to Independent providers who can tender for services, including diagnostic imaging services. The government act introduces ‘Any Qualified Provider’ status. Qualifying organizations can tender for services.

This has been of great concern to some radiology staff working in the NHS. There are real worries about fragmentation of healthcare and destabilization of NHS services, rendering some of them unsustainable due to loss of contract and loss of critical mass. Independent healthcare providers see the reforms as an opportunity to gain greater market share. Quality standards will be a key metric.

A further dynamic in the UK Healthcare system is the publication of an enquiry report into healthcare failings at a UK Hospital Trust. It found serious weaknesses including the way in which patients were cared for. Rightly, there is an increased focus on the patient and their central place in healthcare management.

Radiology has been at the forefront of technology and diagnostic advances. A good example of technology advance, which has been of major benefit, is PACS. In the UK, PACS has a very high penetration with levels of above 90%. PACS has been well accepted and service delivery advances are apparent.

So the question is, “What is next for PACS in the UK and how can PACS engage in the evolving healthcare system?”

The first point is that PACS will need to become even more flexible in its approach. Even before the latest government reform there was reconfiguration of ‘business units’ in the NHS. Trust wide or Health Board wide PACS systems have found the boundaries changing and the need to link with different vendor systems. Radiologists report across new units and patients are managed across new reconfigured units. Patients and radiologists need integrated healthcare records. Super PACS is one approach to this situation and vendor neutral archiving clearly has benefits, but there are ‘softer’ elements to this. New configurations and new systems will need a coherent training strategy.

With the continuing need to be resource efficient and to compete in the AQP market place all imaging providers will need to have good business analytics built into their imaging practices—Should this be a RIS standalone function or should it be embedded in the PACS function? Radiologists and administrators will need dynamic and reliable stats that are part of quality dashboard functions.

As the patient focus rightly increases, images and reports will need to be fully shared with the patient. They will need to have ownership if their consultations with healthcare professionals are to be fully informed. Patients will want to have their radiation records, and all this can and should be part of future PACS.

PACS can do much to support the changing healthcare landscape and the areas which I have listed above are part of that challenge.

Stephen Davies has been a Consultant Radiologist in Cwm Taf Health Board in South Wales UK for 22 years. They were a pioneering site for PACS in the UK in the late 1990s. He has also recently become Medical Director of Medica Reporting, the largest teleradiology company in the UK. He is a member of the Carestream Medical Advisory Board.

Addressing Concerns Behind Meaningful Use

Doug Rufer

Doug Rufer, Director Technical Marketing and Clinical Sales Engineering, Carestream

By now, you have probably been feverishly working to meet compliance with Stage 1 Meaningful Use and right around the corner, Stage 2 is set to begin in 2014.  If you have been keeping up with the latest news on Stage 2, you are surely aware the requirements have suddenly become more difficult and are continuing to increase in complexity.

Stage 2 Meaningful Use requires higher thresholds than Stage 1 (for example, requiring that more than 80% of unique patients have their vital signs recorded as opposed to 50% from Stage 1).  Additionally, two very important changes take center stage that will drive future stages of this program: 1) patient engagement by providing them access to their medical records (allowing access, download, and transmission of that data) within 4 business days of their care and; 2) EHR system interoperability (i.e. data exchange).  But are these requirements being enacted too quickly and is our healthcare system ready for the change?

Chart via.

Chart via.

Patient Record Access

At a recent healthcare IT conference, many attendees expressed their concerns over providing patients access to their information, not that they shouldn’t have access but will providers be overwhelmed by questions from their patients?  An interesting outcome, in a few pilot programs, was patients actually do prefer to have access to their information. As a general rule, most providers have found that their patient’s are not continually calling and asking them questions at all hours of the day and the questions they do ask are more focused on allowing the provider to advise them on how to improve their outcomes.

Another concern that surfaced was meeting the objective requirements that the patient actually access their information.  Not only is it important that a tool be provided for patient access (portal solutions are now required by certified EHR vendors for patient record access), but to meet the measure, the site has to verify that 5% of their patients actually do access their information.  The good news is the CMS reduced this threshold so obtaining the 5% measure requirement should be much more attainable during this stage.

The bottom line is this: providing patients with better access to their health information allows them to ask better questions to their providers.  No longer are we in an era where the patient takes the word of the provider as “gospel” but they are truly, actively engaged in their care maintenance and delivery and can now collaborate with their provider for the best possible outcomes.  This is a key goal of the program and one which, over time, will help bridge the gap that has historically existed between patients and providers.

Data Exchange and System Interoperability

Another area of concern was with vendors being properly prepared for data exchange.  Although there are well established standards today, data exchange is costly and time consuming for many facilities.  Data exchange needs to become more fluid and simplified to allow patient data to be exchanged from one IT system to another.  This is critical for providing better patient care and lowering the cost of healthcare.  Health Information Exchanges (HIEs) are being established throughout the country to accommodate the exchange of patient information.  The HIEs purpose is to facilitate the exchange of key information which grants providers in other locations access to important patient information. This allows them to make better decisions on patient care and eliminate costly repeat procedures.

Finally, imaging of all types (radiology, cardiology, etc.) needs to focus on access as well.  These imaging systems have traditionally been silos of information.  Now that patient data will be accessible through HIEs nationally, imaging needs to be taken into consideration on how to share patient images when their imaging record may span across multiple organizations and PACS systems, yet be readily available with their patient health data.

Accountability and Making Sense of Meaningful Use

At the end of the day, the goals driving Meaningful Use were made simply to lower the cost of healthcare, provide better communication and collaboration among healthcare facilities and practitioners, and improve patient outcomes.  The program set three initial stages to accomplish this goal: 1) Stage 1 was meant to capture data; 2) Stage 2 is meant for use and data sharing in a meaningful way and; 3) Stage 3 plans to focus on data analysis and using the data to improve clinical outcomes (Stage 3 has not yet been finalized, however).

To accomplish the goals of Stage 3, a new model must emerge in the delivery of care and this is taking place with the rise of ACOs and Population Health Management.  ACOs are meant to establish, through a group of providers and physicians, an accountability for the care they provide.  In other words, there’s a shift from “fee for service” to a model where the caregiver is encouraged to deliver higher outcomes and is incentivized to provide this level of care.  Population Health Management is health outcomes by a group of individuals that aims to improve the outcomes of an entire population, not just the individual.  Population Health is getting a lot of attentioimage_myvue_laptop_3n because concentrating on an entire population creates a model to impact costs of care delivery over time.

When factors beyond a single patient are taken into consideration (such as socioeconomic status, environment, and resource distribution of care), and programs can be put into place to improve certain diseases or conditions within that population by equalizing access to the care, the long-term effects will be lower healthcare costs.

What’s Next?

We live in an era that has the most robust access to care and technology to help improve more lives than ever before in history.  But costs have spiraled out of control making access to care difficult for those who need it most.  Getting a jump on this trend by looking at key patient data and outcomes across a population, in time, can help bring these costs back under control.  Managing population health will help drive down costs of chronic conditions within a given population by better understanding the drivers for such a condition and developing and administering preventative programs early on.  All this can only be achieved by capturing data, having open access to the data, and the right tools to analyze it.  So the next time you are struggling with the “why” behind capturing data and the fuss of this program, know you are on the forefront of changing the delivery of patient care in the future, and that in and of itself, is a goal worth striving for.

VNA Usage Trends and Medical Imaging Storage Needs

Cristine Kao

Cristine Kao, Global Marketing Manager, Healthcare IT, Carestream

According to a recent report published by IHS, the compound annual growth of VNA storage worldwide from 2011 to 2017 is expected to be at 48%. With the benefits VNA has to offer such as data management, disaster recovery, communications and security, the expectation is to drive increased use of this technology and make it the preferred storage platform for medical imaging.

IHS recognized three main VNA delivery models: non-hosted, hosted, and hybrid. The report confirmed that non-hosted VNA models continue to dominate in the world market. However, the chart also shows that hosted VNAs are predicted to grow at the fastest rate out of the three. This should not come as a big surprise since cloud services continue to grow in the healthcare industry, and hosted storage space for medical images has grown threefold since 2005.

VNA model

More interesting is the breakdown of these statistics by region. It is clear from each breakdown that hosted VNAs are going to be the biggest growth area, but some regions, such as EMEA, are predicted to slightly decrease in hybrid and non-hosted VNAs by 2017.

VNA models EMEA

In the Americas, strong growth is predicted across all three business models, with hosted showing the second largest percentage of growth among the three regions.

VNA models Americas

The Asia Pacific region is predicted to have the largest hosted VNA growth of all the regions. More surprising is that non-hosted VNA adoption will continue to grow at a healthy rate through 2017. With adoption being so low in 2012, and strong progress made in 2013, it is clear that this region poised to be leader in VNA usage.

VNA models Asia Pacific

Healthcare providers around the world view on-site vendor-neutral archiving platforms as a reliable solution that simplifies data management and enables secure information sharing across multiple locations or users. In addition to helping equip clinicians with a comprehensive view of patient clinical information, cloud-based archiving can simplify and consolidate storage resources to reduce costs and enhance workflow by eliminating departmental silos of clinical information.

While we are proud at Carestream to be ranked as the third largest VNA supplier in the world, we recognize that there is still a long way to go when it comes to meeting the storage, protection, and access needs of our customers. We, and all VNA providers, certainly have our work cut out for us to meet these trends in an effective and efficient manner. It is a challenge and one we embrace and look forward to meeting.

Guess the X-ray– September’s Image Challenge

Congratulations to the person who correctly identified August’s X-ray image– it was a high heel shoe! Below is the “Guess the X-ray” image for the  month of September! Please leave your answer in either the comment section below or on our Facebook page. The challenge will run until September 30 or until the first person correctly names the item in the image. Good luck!

Sorry…Carestream employees and their agencies are prohibited from entering.


September Image