Monday, December 7, 2015

My 2015 RSNA top ten.

View from the cafe
to the exhibition floor
This year’s annual radiology tradeshow at McCormick Place in Chicago drew about 10 percent fewer attendees than last year, which is most likely attributable to the unfavorable dollar exchange rate, which makes it expensive for non-US attendees, and the fact that last year was kind of a banner year as it was the 100th anniversary meeting.

It was my 32nd meeting and I consider this year’s as one of the uneventful ones. I had a hard time finding any new products let alone innovations. Of course, vendors would like you to believe otherwise but I couldn’t find anything exciting about a new release of an existing device or product or vendors catching up with the competition or technology that was already introduced several years back. In any case, here is my top ten list of noteworthy observations:

1.       VNA is out for the PACS vendors: Several PACS vendors have started to realize that the Vendor Neutral Archive (VNA) is here to stay, and instead of trying to offer one themselves, it is better to accept its presence in the marketplace from other specialized vendors, and work either around, or with them. To offer a VNA as part of your PACS product line does not make that much sense anyway as it kind of defeats the purpose of uncoupling the image management-archiving component in a “vendor neutral” offering if all components are yours. A PACS vendor does not have any incentive to uncouple these, and instead of implementing an open standard for synchronizing the PACS and VNA such as IOCM (image object change management) it will continue to tightly couple that and use its own proprietary communication anyway.

As a consequence it seems as if the ground between PACS and VNA vendors has been divided and both are starting to live with it. It was also interesting to see that some of the archive vendors are starting to provide dashboards, add analytic tools to create additional value, something that makes sense: it is all about using “big data” and remember, digitization of imaging has been widespread for at least 15 years while the EMR implementations only started to take off for the past five years in the US, so there is potentially much more to work with.

2.       What happened with the deconstructed PACS? The good news is that the doom and gloom as was portrayed during the recent SIIM meeting about PACS being dead, and that it might be better to build a best of breed solution using what was coined as a deconstructed PACS, was absent during this meeting. It takes a lot of work to tie all the pieces together and system integration is challenging, something that is exactly what PACS vendors have been doing for many years. The ability to provide image exchange between multiple vendors with access and prefetching from multiple, old, obsolete and retired PACS systems is what providers are looking for. That includes access to imaging from different specialties and departments, which can be challenging as some of the large institutions might have 50 or more locations and/or departments that create images. It seems that the consensus was that a “constructed” PACS makes more sense than a “deconstructed” PACS for most institutions.

3.       Do we need yet another certification? During the event, the new RSNA Image share Sequoia project was launched with a presentation by Dr. David Mendelson from Mount Sinai. This is an activity sponsored by RSNA that will initially focus on validating image sharing between different institutions using IHE profiles such as XDS, XCA and XPHR. It is kind of a follow-on to the ehealth exchange, which is mainly for exchanging documents between what was quoted as used between 35 percent of all US hospitals. Talking with some of the vendors, there seems to be a concern about yet another venue for testing and validation in addition to the annual IHE connectathon, which happens in multiple locations (USA, Europe, Asia, where a vendor can be IHE certified using the ICSA lab tools. The good news is that the core of the Sequioa tools are going to be based on the MESA toolset as used by the IHE connectathon, nevertheless, I can understand the concerns from a vendor perspective. Time will tell which method or venue, if any, will eventually prevail.

The "O-Arm" (Pac man?)
4.       The evolution of the C-arm: Most innovations are not really revolutionary but rather evolutionary. A good example is the evolution of the C-arm, intended to provide limited fluoroscopy and also basic x-ray imaging in the ER and OR. There are now variations called “O-arm” which has a movable opening and “G-arm” which combines two detectors and sources to take two views.

Specialized orthopedic
5.       Cone beam CT scanners are becoming more popular: The initial cone beam CT scanners, which take volumetric scans using only a single rotation uses a
flat detector instead of the small, cylinder arrangement used in a conventional CT scanner. They are predominantly used for dental applications as the high resolution is very well suited to create data for dental implants and it is relatively affordable for this specialty ($100-200k). Its application is now being extended for head imaging as well as extremities. There were at least two vendors that showed it for orthopedic applications and vendors are also promoting it for more extensive head and sinus imaging. The dose reduction compared with a regular CT is significant, i.e. 4 to 5 times, as a matter of fact, one vendor markets it as a low-dose CT system.

6.       Thermography is becoming mainstream:
New Thermography therapy modality
This is a good example of a relatively new modality that is being applied not only as a diagnostic device, which has been around for at least five years, but now also as a therapy tool. It is typically used in addition to radiation therapy to treat cancers and apparently the heating of the tissue using microwaves gives better radiation treatment results. The way it is applied is by using several heat sources arranged in a circle so that the treated organ can be targeted very much like regular radiation therapy from different directions while the skin is cooled by a water bag touching the surface.

Promotion of DBT claiming that 39%
of woman are covered by DBT
7.       Digital Breast Tomosynthesis (DBT) is becoming the norm: Hologic has set the standard in this field and other vendors are still trying to catch up, but there is no question that DBT will replace conventional 2-view breast x-ray imaging. I would have expected that breast MRI would actually be a better candidate to replace it but I guess the cost and contrast issues just makes it not yet a viable alternative. Finally, most PACS vendors are now facilitating the new DICOM objects that are created by the DBT modality instead of having to deal with the proprietary solutions that were used initially. But, facilitating these studies, especially prefetching them, is still challenging as they are about ten times the size of a conventional mammogram study. In addition, despite the fact that the radiology community has accepted that there are probably a couple more findings detected using this technology for every thousand studies, I have not found anyone who really likes to read and report on them, mostly due to the fact that it takes 3 to 4 times longer to read these studies.
Affordable wireless DR
plate technology

8.       DR is starting to get affordable: Most vendors are not even displaying their CR systems in their
booths anymore, as they are really pushing their DR plate technology. I would argue that for countries outside the US, when converting to digital for the first time, a CR solution is still not only more affordable but also less risky, as dropping a DR plate can cost $40,000 or more. But in the US, most customers opt for digital plate solutions as plates are getting more affordable with wireless plates for around $30k (as well as insurance coverage for DR Plate Drops). Plate vendors are reporting record sales, i.e. growth of 50 percent a year for these plates.

9.       3-D models replacing films? 3-D printing has been demonstrated for several years but the technology is now becoming mainstream, as it is making its way into the consumer world. You can buy a 3-D printer at Amazon or Walmart for under $1,000. There was a lot of talk about this technology at this year’s event. It is interesting that apparently, computer visualization is not as good in replacing real-world, touchable models that are used by surgeons, for example, to determine the best way to operate on a defective heart. This use of 3D printed models was recently featured by CNN as being especially useful for unusually complicated procedures.

Medical casters? Really?
10.   Medical grade what? One of the first lessons I learned when I started working in the medical field

is that the “medical grade” label sells. It is often just a marketing tool. For example, there are medical grade CD and DVD’s, which are basically the same as you can buy at Best Buy or Walmart but with a different label or color. The company I was working for at one time used to simply spray-paint the standard computers (which were DEC pdp-11 at that time) in a white color to be able to charge more for medical grade. Of course, if there is indeed a difference, such as when using medical grade monitors, which typically allows for DICOM calibration and automatic luminance control, the term makes sense. But in general, I’d always be suspicious when I see these labels on what appears to be commodity products.

Macy's window display.
RSNA belongs to Chicago: RSNA would not be RSNA without the grumpy (this is an understatement) cab drivers, expensive food, almost unaffordable lodging that you find in Chicago.
Click here for details
An added feature this year, however, were protests spurred by the release of a video of a shooting event that had occurred more than a year ago. The protests shut down Michigan Avenue on the Friday before the event, and during the week. And then, there is nothing better than walking in the brisk air coming off Lake Michigan, the window displays at Macy’s, State street, and meeting people from all over the world in the bus going from your hotel to the event. Even though there might not be many new things again next year, I am pretty sure I’ll be there again, in case I missed you, hope to see you then!