Saturday, June 23, 2012

Reading Radiology from your Smartphone, Really?

I wouldn't read this type
of images from my smartphone
There has been an explosion of healthcare “apps” for wireless intelligent devices such as smart phones and tablets. Not only are numerous utilities available for consumers, such as the one I have on my phone to record my heart rate, but there are also add-ins that are used by physicians. An example of this is the one that connects the ICU physicians at Cook Children’s Medical Center in Forth Worth with real-time data from the neo-natal unit, or the one that the physicians at the Dallas Medical Center use to show the fractured leg of my little grandson to his mom after he fell on the playground at his day care. And there is no end in sight as developers look to develop tests for people who have diabetes, and I can imagine that pacemaker data can be exchanged as well as many of these new devices now have blue-tooth or other wireless interfaces.
This is all great but every fast new development has a risk that the regulatory agencies and the trade associations will be playing catch up to provide appropriate guidelines and checks and balances to advise the use of these devices and protect the interest of patients. Case in point: I just came back from a PACS training onsite at a major hospital where the radiologists are reading chest radiographs on their laptops and even tablets. These devices are great for communication between physicians and also their patients, but one should never, ever, ever, use these devices to make a diagnosis. The AAPM has developed a set of guidelines for testing and evaluating monitors (see also white paper on “what monitor to use”). If I take one of their most important images, the so-called TG-18 QC test pattern and display that on my laptop, I can barely see half of the grayscale values that are supposed to be visible. The impact of this poor presentation is obvious: anatomical findings that differ only a few grayscale values will totally disappear.
The problem with using un-calibrated commercial grade displays for diagnostic purposes is not new. Some PACS vendors have been known to offer poor quality monitors as part of their package to undercut the price of others in order to get a sale. Not only does this impact patient care, but also exposes them to a major liability. I was called as an expert witness in a case where a radiologist was asked by a judge about his familiarity with the ACR guidelines for teleradiology and the use of the appropriate monitor for his job. I also have had some of our PACS administrator students tell me that they had to pull calibration records from prior years to show that the monitor which was used to make a disputed diagnosis was indeed calibrated.
The good news is that there are many reputable institutions that do indeed have a monitor quality control policy and procedures in place. Interestingly enough, for digital mammography, regular calibration and the use of FDA approved monitors is required. I am puzzled by the fact that this is not the case for diagnostic monitors, as I would assume that missing the indication for breast cancer is of the same level of risk as missing an indication for lung cancer. However, the FDA does not appear to think the same.
Now back to the use of the intelligent wireless devices, there is no question that these will make a major impact on the delivery of healthcare and that they will improve the exchange of information that will make healthcare more effective and safe. However, I surely hope that these will be used with caution and that regulatory agencies and trade associations such as the RSNA and HIMSS will catch up and put guidelines out and educate users on how to use these effectively and safely.