Wednesday, December 7, 2016

RSNA 2016, What’s New?

This year’s annual Radiological Society of North America (RSNA2016) tradeshow in Chicago was
pretty good, the weather was cooperating, the labor unrest and strike from Lufthansa and workers at O’Hare just ended in time for us to get to the city, and the overall mood and atmosphere was positive. Vendors were happy about increased traffic from serious buyers and contenders, and the PACS replacement market seems to be growing. Here are my (subjective) observations:

1.       Deconstructed PACS is here to stay. I have to say that I was surprised by this as I thought it was going to be a fad, and, would only be for a few selected large organizations, but it seems to have a lot of momentum. I wondered why would anyone start building a PACS from scratch using components from best-of-breed vendors knowing that it takes a substantial investment of time and expertise to do this? Well, the reasons are:
a.       There are significant workflow improvements that can be achieved that are not possible or are very hard to do with “standard” PACS systems. Examples are, doing efficient image exchange; having universal worklist reading from multiple, disparate PACS systems; having an elaborate pre-fetching algorithm that makes sure you pull all prior studies; having optimal mapping of your HL7 based orders into a DICOM Modality Worklist that supports an effective technologist workflow, and several others.
b.      There is an emergence of middleware vendors that provide routers, DICOM tag morphing gateways, worklists, decision support software and workflow support
c.       Finally, we have more availability of zero-footprint viewers that are fully featured, i.e. are not just lightweight clinical viewers, but can do the heavy duty radiology work, and can operate either driven by the EMR, RIS and/or a general purpose worklist
d.      VNA installations are maturing, and now provide full control over the image archive to the end-user instead of locking the data up in semi-proprietary vaults, which required the user to keep on purchasing additional licenses for blocks of studies to be archived and/or accessed.
There are still challenges, as we find out how much proprietary information typically flows in between the various PACS components, but there is no question that the deconstructed PACS is here to stay and a good solution for larger organizations with good in-house IT and clinical support.

2.       The deep learning or machine learning hype, which are both forms of Artificial Intelligence has spread to radiology causing more harm than good at its onset. A story in the September 2016 Journal of the ACR stated that it could end radiology as a thriving specialty. As Dr. Eliot Siegel from the Baltimore VA stated in the controversial session “Will Machines Replace Radiologists?,” he is already getting emails from residents asking him if they should quit the practice. A Wall Street Journal article published on Dec. 5 discussed the AI threat and dismissed its short term impact based on three barriers: the lack of huge sources of data that are needed to “teach” these supercomputers the rules, the small incremental improvements (one or two percent) that are achievable that are not necessarily significant enough to justify the initial investment, and the lack of personnel to implement all of this. There is no question that improvements in technologies such as CAD will spread its use outside the common application of detecting lesions in breast imaging, and that radiologists could use computers much more effectively such as for automating reports using structured measurements from ultrasound. But replacing radiologists with computers will take a while, if not a couple of decades.

3.       3-D printing is gaining a lot of traction. This technology is not new; for the past 30 years the

automotive industry and other industrial applications have been printing models for rapid prototyping and hard to find replacement parts. But it has now become mainstream technology as you can go on-line and buy a 3-D printer for a few thousand US dollars. Larger institutions are starting to set up 3-D printing labs, which is somewhat of a challenge from an organizational perspective as it does not quite fit one specialty. The application intersects radiology, surgery, orthopedics, dentistry and others. But the number of models to be printed have exponentially grown, as the Mayo clinic reported for example that they now do several hundreds of models a year. The DICOM standards committee, which met during RSNA, decided to re-activate a 3-D working group to address the
interoperability issues. There are several standard 3-D formats that are similar as with, for example, a standard JPEG or TIFF 2-D image, but there is no place to put acquisition context, patient information, and other clinically important information in the meta-
data. In other words, we need a DICOM “wrapper” that allows this, and that can encapsulate the most common standard formats similar to what is done by “wrapping” a pdf file into a DICOM file format. This activity is expected to give this application a major boost so that these objects can be properly managed.

4.       Digital Radiology (DR) plate technology shows signs of maturing. There are three major
technical challenges with regard to DR technology that are showing signs of being solved in the next two to three years. These have to do with the top reasons that these plates are currently failing. The first one is weight and lack of robustness, which has to do with the fact that the detector is using glass as its main component. The same technology that is currently being used to create thin TV screens that are bendable should resolve this issue and result in super light-weight detectors. The second challenge is to make these detectors completely waterproof so they can withstand body fluids. The third challenge has to do with the way that the detector array is soldered, which should be manufactured in a more robust manner. Given the recent regulations by the US government to encourage DR replacements of CR, the volume should be going up, which should bring the price down for a plate from around US $50,000 to an average $25,000 and even lower. We are not quite there yet, but the next few years should provide some major improvements and cost reductions.

5.       Multi-modality integration is becoming more popular including such dual imaging devices as the PET-CT, PET-MRI and even using SPECT. In addition, it is also possible to integrate an ultrasound with a CT scan by connecting a dual camera to the probe and registering it with a prior CT scan. This could potentially even replace the often-used practice of using an X-ray fluoroscopy (C-arm) for visualization of needles inserted into a patient.

Usually, I have a “top-ten” list after RSNA, but this year I did not find that many innovations, not taking the new “60 second eye-lift,” or massage chairs into account. However as mentioned, the “vibe” was very positive and there was a lot of emphasis on how to become more efficient, how to improve radiology services, which combined with a concern for how the president-elect is going to impact the way that medicine is
practiced, resulted in a careful optimism. As always, I personally enjoy these tradeshows as there is no better way to get updates, talk to many peers, learn a lot and know what is going on in the industry than walking the aisles!