Video: What the Future Holds for Digital Breast Tomosynthesis (DBT)

At SIIM 2015, Carestream’s own Ron Muscosky, worldwide product line magager, Healthcare Information Solutions, participated on a panel about digital breast tomosynthesis (DBT).

We covered the audience questions in more detail in an earlier blog post, but in the video below, Muscosky explains the purpose behind the panel, the challenges DBT presents, how vendors are addressing these challenges, his comments on the audience’s participation, as well as what he believe the future holds for DBT.

Diagnostic Reading #30: Five Must Read Articles from the Past Week

Carestream LogoAnother week means another edition of Diagnostic Reading where we highlight five must-read articles published in the last seven days. This week’s articles focus on Stage 3 Meaningful Use, dense breast tissue, VNAs, breast cancer screening, and mobile app adoption among radiologists.

1) Proposed Rules for Stage 3 Meaningful Use – Imaging Technology News (ITN)

Dave Fornell of ITN goes into details for each of the eight objectives for Stage 3 Meaningful Use set in place by the Centers for Medicare and Medicaid Services (CMS). The eight objectives include: 1. Protect Patient Electronic Health Information; 2. Electronic Prescribing; 3. Clinical Decision Support (CDS); 4. Computerized Provider Order Entry (CPOE); 5. Patient Electronic Access to Health Information; 6. Coordination of Care Through Patient Engagement; 7. Health Information Exchange (HIE); and, 8. Public Health Reporting.

2) Making Sense of Dense Breasts – Imaging Technology News (ITN)

Jeff Zagoudis of ITN discusses how as states continue to mandate patient notification of dense breast tissue, the technology for analyzing and reporting continues to evolve. A big issue today is how almost all in the medical community know about the impact of breast density, but that knowledge has not been passed down to patients. The article dives into the how many states in the U.S. are working to notify patients about dense breast tissue, and other modalities to get a second read of the exam.

3) NEJM: Breast Cancer Screening Reduces Mortality by 40% – AuntMinnie

“Researchers from the World Health Organization’s International Agency for Research on Cancer (IARC) found that women ages 50 to 69 who regularly receive mammography screening reduce their risk of dying from breast cancer by 40%, compared with women who are not screened. This translates into about eight deaths prevented per 1,000 women regularly screened, according to the group.”

4) SIIM 2015: VNA Adoption Yields Workflow, Cost Benefits – AuntMinnie

In this session from SIIM 2015, Wake Radiology was able to realize the benefits of a vendor-neutral archive (VNA) such as improved workflow, better management of digital breast tomosynthesis (DBT) images, and reduced storage costs.

5) Q&A: Radiologists at the Forefront of Mobile App Use – Diagnostic Imaging

The Q&A is with David Hirschorn, MD, director of radiology informatics at Staten Island University Hospital, in which he discusses a panel he participated on at ACR 2015 called, “Reshaping Radiology Through Mobile: Apps, Technologies, and FDA Regulations.”

Importance of Viewers in Enterprise Imaging

Marianne Matthews, Chief Editor, Axis Imaging News, recently spoke with Cristine Kao, Global Marketing Director, Healthcare information Solutions, Carestream, and the focus was on viewers and the important role they play in enterprise imaging.

It is not so much the technology as what the viewer enables that makes them so important. Collaborative care between users is at the essence of what makes viewers so powerful because diagnoses and treatment planning need to be based on looking at and having access to the same information.

The interview, which can be watched in its entirety below, also toucheson FDA approvals for enterprise viewers, and which ones need to go through FDA clearance and which ones do not.

DBT: Is It Ready for PACS Prime Time?

SIIM 2015 LogoOn the final day of SIIM 2015, a vendor panel took place that looked at the evolution and adoption of digital breast tomosynthesis (DBT), and whether or not facilities were prepared to handle the influx of these 3D images on their PACS, as well as across their IT networks.

The panel was led by David A. Clunie, PixelMed, and consisted of Ron Muscosky, MSEE, Carestream, Steve Deaton, Viztek, Mark Bronkalla, MBA, Merge, and Bobby Roe, Visage.

After the vendors each took turn describing their own offerings and advice to those who currently use DBT or are planning to, we segued into an audience Q&A that dived into more detail among the seven audience questions. Below are the questions asked, as well as answers provided from the panel.

Question #1: Secondary capture–should facilities be talked out of it?

Answer: The option exists to store in a standalone archive, or in a PACS and then have the DBT images converted. The issue is that once converted into a PACS, facilities now have double the storage needs as two images now exist. Among panel attendees, they all either had DBT in place, and planned to have it within the next 12 months. However, few who were planning deplpy DBT had a plan in place. Essentially, facilities need to put priority on BTO (Breast Tomosynthesis Object) over SCO (Secondary Capture Object) for improved flexibility in storing and sharing images.

Question #2: What is the clinical impact of DBT? Does it take three times as long to read the exams?

Answer: This answer to this question was diverted to the audience, where one attendees traditional 2D mammography took 10-20 seconds to read, versus DBT exams which took 20 minutes. Attendees knew reading DBT exams took longer, but not that long. The panel responded to this answer by saying that DBT was still relatively new and as adoption and familiarity increased, reading time would become more efficient.

Question #3: Will reimbursement for DBT improve? Especially after the stick-shock for installation?

Answer: When DBT was not reimbursed, few were using the technology. Now that more are using the technology, reimbursement is in place, though it is consider poor. For improved reimbursement, the introduction of new competitors will drive purchase and installation prices. Carestream’s Muscosky said that he has been seeing many facilities adding DBT for competitive reasons, because they do not want to lose patients to other facilities that have it installed. There are of course diagnostic benefits to DBT, and in turn providing better patient care. Essentially, facilities should be installing DBT to maintain an edge on the competition, and use it as a marketing device for the facility. A large majority of the audience agreed with this and are currently practicing this themselves.

SIIM 2015 DBT PanelQuestion#4: Regarding size of images–how can DICOMweb help with performance issues?

Answer: One response was that is does not matter one way or the other if facility is handling everything on the server side. Another response was that any image being view for mammography is either lossless or not. High resolution, no bandwidth advantage to the client, because you want to have a viewer that does not need the entire study to start display or the entire object to start display. Server-side issues have advantages but is not a silver bullet. Facilities can user server-side for non-diagnostic, or offer a choice on whether facilities want loss or lossless, and server-side is not truly offering bandwidth advantages.

Question #5: This audience member asked about digital mammography priors for comparison reasons that has resulted in a struggling workflow. She had to alter workflow because her facility cannot get to prior to workstations fast enough. Has this problem been fixed with digital mammography?

Answer: The issue with the attendee’s facility was that there are multiple offices, but read at one central workstation. The facility is sending all studies to all workstation, creating three or four copies. Routers would send study once across, and central location would route once. The solution to this is that intelligent routing would mitigate the issue. Technology that is zero-footprint has not been available, whether supporting server-side rendering or not, but it is moving in that direction. All of this re-routing goes away once facilities move to the cloud. Panelists commented how it is important to focus on not just getting diagnostic tools to diagnosing physician, but also having good bedside manner with patients. Carestream’s Muscosky added that many facilities are converging multiple sites, and data needs to be accessed quickly no matter where from. Data cannot be sent around among facilities and re-routed.

Question #6: Is the industry moving toward supporting motion detection and correction?

Answer: Panelists all agreed that this advancement would need to be completed on the image acquisition side, since these vendors are the ones creating the hardware. They all agreed that it would great to see projection when there is motion, but have not heard of anyone released a motion detector.

Question #7: How do facilities correct hanging protocols that are not working?

Answer: One true way to identify an image according to view, and every view port has to give the user an option to toggle between C-view, and others. Facilities should refer to the IHE DBT framework. There was an idea presented that in the future, vendors should allow hanging protocols that make more sense and are deterministic. Users still want to hang right, regardless of vendor, and new modality gives a chance to hope for the best compliance. In the future, there will need to be a right code that allows users to apply logic and alternate paths to identify mishaps.

PulvinoRich Pulvino is the digital media specialist for Carestream. He attended SIIM 2015 from May 28-30 at the National Harbor in Maryland.


Imaging’s Place in Value-Based Healthcare

SIIM 2015 LogoThe answer to a question asked in a SIIM 2015 Friday morning session was clear–medical imaging needs to make further progress to be in a position to provide value-based care.

This was the focus of Rasu B. Shrestha, MD, MBA, University of Pittsburgh Medical Center, John W. Nance, MD, Johns Hopkins University, and Kevin W. McEnery, MD, University of Texas MD Anderson Cancer Center in the session, “Providing Value-Based Healthcare – Should Imaging Lead, Ride Along, or Get Left Behind?”

Radiology: Data Rich, Information Poor

Dr. Shrestha began the session by focusing on what we mean when we talk about value-based care, how radiology needs to get to where it needs to be, and the opportunities to get there by discussing the barriers that are currently preventing this from happening.

The state of radiology is that the specialty is data rich and information poor. It has commonly had its innovators, and has led the charge in healthcare innovation (film to digital, etc.), but its innovation over the years has also been its downfall, as numerous silos have popped up within healthcare providers. The next stage for radiology is breaking down those silos and extracting the data so we can comb it for information, which according to Dr. Shrestha’s slide, showed that from the information we obtain from data, we can then gain knowledge about the patient(s), and eventually turn that knowledge to wisdom, with increased value provided to the patient along the way.

The main problem with the imaging workflow today is that radiology is image-centric and not patient-centric. The specialty stopped talking to other specialties within the hospital as it drowned in too much data, and not enough intelligence. Moving forward, context will be king–both obtaining context to produce better reports, and providing additional context once the exam has been done and the report created.

Dr. Shrestha’s main point was the importance of data liquidity, which is freeing data from the silos, liquidating the assets because of the immense amount of value it hold. The problem is that radiology has not been able to do this.

The technologies currently being developed will radiology in this direction. The next generation will be patient-centric, predictive protocols, cloud-based VNA, adaptive learning, contextual reports, and value-based imaging.

Radiology can only improve what it can  measure. In a volume-based imaging model, report turnaround time, and number of studies read were the metrics. Moving forward, it will be superior outcomes, patient-centric care, clinical quality metrics, increased transparency, total cost management, and shared savings.

Definition of Value

Following Dr. Shrestha, Dr. Nance of Johns Hopkins University looked at the definition of value, its history in radiology, its current status, and barriers.

He started out with the honest definition of value, which is:

Value = Outcomes/$

Value does not equal quality, efficiency, safety, outcomes, or cost, per se, and he highlighted that there is currently an alphabet soup of organizations (government, nonprofit, associations) currently focused on outcomes, because the current measures are certainly not.

Dr. Nance went through common measures, and how diagnostic imaging is not a big part of them. The Healthcare Effectiveness Data and Information Set (HEDIS), has 81 measures and only three have anything to do with diagnostic imaging. None related to outcomes. Physician Quality Reporting System (PQRS)–254 measures, and only 13 deal with diagnostic imaging. Again, none related to outcomes. National Quality Forum has 636 measures, with 15 having to do with diagnostic imaging, even though imaging account for 14% of healthcare costs.

The fact is that diagnostic imaging lacks outcome measures.

ACR’s Imaging 3.0 is heading in the right direction by seeking to improve the value of radiology. The types of quality measures are focused around structure, process, and outcomes. Structure focused on underlying infrastructure of a system, which has serious limitations. Process measure are most common, contain a lot of value, have some advantages that are actionable, but again, have serious limitations. This is because people gravitate toward measures that are easily extractable, even though they may not be the most relevant.

Why are outcomes so allusive? You need data validity. Stringent national benchmarks, which are often lacking. Large sample sizes and follow up to show differences. There are good examples out there with large, randomized controlled trials, but it is not commonplace yet.

The challenge moving forward for radiology in this area will be diagnostic accuracy, the quality of communication, change in management of the specialty, and the effect on outcomes.

Transitioning from Volume-Based to Value-Based Imaging

Finishing up the session, was Dr. McEnery of University of Texas MD Anderson Cancer Center.

The objectives for his section centered around examining the transition of imaging from volume-based to value-based, and discussing the role of informatics support in demonstrating the value of enterprise imaging in the transition to value-based healthcare.

In a value-based system, Dr. McEnery showed that we must be achieving outcomes at the lowest cost that are patient-centered, focus on the patients’ needs with their outcomes achieved, and focus in the right locations for high-value care.

For high-value, the value-enhancing IT platform accomplishes the following:

  • It is centered on patients
  • It uses common data definition
  • It encompasses all types of patient data
  • The medical record is accessible to all parties involved
  • The system includes templates and expert systems for each medical condition
  • The system architecture makes it easy to extract information

With the change from volume-based to value-based imaging, we will go from being:

  • Transactional to consultative
  • Radiologist-centered to patient-centered
  • Interpretation focused to outcomes focused
  • Commoditized to integral
  • Invisible to accountable

The imaging value patient context that Dr. McEnery showed was:

  • Orders: Appropriate for the patients’ complete presentation
  • Protocols: Optimized to inform the clinical decision process
  • Acquisition: Optimized to inform at safest level, greatest clinical data
  • Interpretation: Focus on findings that are pertinent to patient
  • Reports: Optimized to efficiently show the information, data, and results

Dr. McEnery went on to explain how these changes to value-based care are on the way as health reform continues to take shape. This included the April 1, 2016 deadline of CMS lists qualified decision support providers for ordering professionals, and beginning January 1, 2017, CMS will not reimburse certain claims.

With these changes inevitable, Dr. McEnery ended his session focusing on the clinical decision support (CDS) process and how it will move diagnostic imaging to a value-based process. Essentially, CDS and EMR needs to inform the entire patient process, and significant changes are in process for the delivery and reimbursement of healthcare.

IT systems will need to evolve to allow radiologists to become a part of this evolution. As Dr. McEnery said at the beginning of his session:

“I don’t want to be in the backseat. I want to ride shotgun. I want radiology to ride shotgun in the innovation process.”


PulvinoRich Pulvino is the digital media specialist for Carestream. He is attending SIIM 2015 from May 28-30 at the National Harbor in Maryland, and will be publishing blog posts throughout the event.


The Next Imaging Evolution Will Contain a New PACS

SIIM 2015 KeynoteThe theme of SIIM 2015 is “Creating the Image Enabled Enterprise”—a mission to bring radiology and imaging informatics to the forefront of healthcare enterprises.

This theme came through loud and clear in Donald K. Dennison’s opening keynote, “The Next Imaging Evolution: A World Without PACS (As We Know It).” Dennison was not explaining how PACS would eventually go away, but highlight how the way in which the technology is built, the capabilities it provides, and the way in which it is used will change–moving from a departmental technology to one that is integrated throughout the healthcare provider enterprise and EMR. In fact, that change is happening faster than we may believe.

Dennison kicked off the keynote describing the three main forces that are currently changing the world RIS and PACS:

  1. Payment reform shifting from volume to value-based reimbursement models
  2. EMR adoption
  3. Consolidation of healthcare providers with larger ones buying or affiliating with smaller hospitals, care facilities, or imaging centers

From there, Dennison moved on describe the current state of imaging in the 2010s. The section on departmental vs. enterprise imaging focused on how imaging is managed today, and how it will need to move to the enterprise model moving forward. Departmental imaging isolates radiology, but still contains numerous imaging informatics benefits such as uniting the VNA, enterprise viewer, image archive, PACS, radiology portal, and reporting within the radiology department.

Enterprise imaging will move this information throughout the organization, and will be dependent on the discovery, presentation, storage, and management of the imaging data.

To accomplish this, Dennison highlighted governance as being the key. If IIPs are not sitting down with Document Management and EMR people, this could lead to duplicate work. Governance on where the imaging data is going to be put and how providers will access it is a must. Doing so will result in an informatics that is sensible, indexed, and presented in context when accessed.

Dennison went on to tackle clinical decision support (CDS), interoperability with Web APIs such as HL7 and DICOMweb, multimedia-enhanced radiology reporting, and how there is a plethora of informatics that must be measured if quality is truly to be achieved today.

He arrived at what PACS vendors need to do in order to meet these pressing needs, and it essentially came down to using a PACS in a single-vendor system–encouraging vendors to make a better PACS. One that is engineered to integrate the worklist, image display, report center, and advanced visualization. It must be easier to deliver MERR, there should be one desktop to manage, and should add VNA-like features to the PACS server.

For providers, it is much easier for them to manage all of these capabilities with a single PACS vendor than managing a different vendor for each one.

In his closing remarks, Dennison commented on how imaging informatics professionals have a lot to offer in an era of consolidation, standardization, and integration. Professionals must have a plan in place and they must share it outside their department walls. Every IT investment must have measureable value, and a policy must be developed for imaging record quality—going back to the importance of having governance in place.

Consistency and completeness of records in the age of interoperability and EMR access will be vital, so professionals must be ready to prove their value, because as Dennison said, “Evidence is king.”

PulvinoRich Pulvino is the digital media specialist for Carestream. He is attending SIIM 2015 from May 28-30 at the National Harbor in Maryland, and will be publishing blog posts throughout the event.