Friday, December 6, 2019

My RSNA2019 top ten.

Welcome to my 36th (!) RSNA

I always enjoy RSNA, it is good to catch up with old and new friends, see what is new in our world of radiology, and last but not least enjoy a piece of deep-dish pizza or a Wiener Schnitzel and Apfelstrudel at the Christmas market. 

Here are my observations:

1. RSNA this year was all about AI. Several major vendors were exhibiting AI driven workflows and new clinical applications for this new phenomenon. In addition, if you were able to make it to the basement of McCormick place, you would find a dedicated hall just for the AI vendors. However, the size of this so-called AI Showcase was in inverse proportion to the amount of traffic, maturity of the products, and number of real-world implementations.
The AI "basement"
There is no question in my mind that AI is still very new and, except for some niche clinical applications, still has a long way to go before large-scale deployment is going to happen. I asked several vendors how many installs they had and the answer ranges from a couple to maybe a few hundred, which compared with the number of hospitals worldwide is a drop in the bucket. In addition, there was relatively little traffic in the dedicated AI hall, much less than at the other two main exhibit floors, so AI did not appear to be top of mind for most attendees.

AI at its best:
integrated with a PACS viewer
There is no question that AI in the long term will become ingrained in the daily workflow and add significant value and increase specificity and sensitivity to the diagnosis by supporting the diagnostic process, however, it might be a couple of years before we’ll see an impact, especially in the day-to-day work of radiologists who work outside the major academic centers, where most of the initial implementations are being tested and deployed.

This is how it should look:
Path on left and Xray on right
2. Digital pathology is taking off in the US. Several western and northern European countries are at least 5 years ahead of the US as they started implementing digital pathology 5+ years ago. FDA approvals held up deployment in the US, but recent clearances are allowing its implementation. There is also an issue with return on investment, which is negative, as you cannot get rid of the slides containing the specimens. There are actually extra costs as now you’ll need to get slide scanners, view stations and an image display and management infrastructure. The good news is that the lag in implementation allows the US to learn from early experiences and become leading edge instead of bleeding edge. 

Why is pathology important for radiology? The reason is that pathology images and reports provide a valuable additional datapoint for the radiologist. Initially, physicians would only look at shared pathology images during tumor board discussions, but there are other applications such as for screening immigrants who typically get an x-ray and possibly lab test to look for infectious diseases.

Another major impact of the implementation of digital pathology will be on image and archive management. It is very likely that these images will be stored on the radiology PACS archive and almost certainly on the enterprise archive or VNA, assuming that the facility has one. Most departments are still trying to manage the onslaught of the additional data from 3-D breast images (DBT) filling up the available data storage at least,  if not more than twice as fast. Wait until you get whole-slide scanned images from pathology, that are multiple gigabytes in size.

POCUS from GE,
innovative 2-sided probe
3. POC (Point of Care) ultrasound is continuing to make inroads. Stanford recently put a POC-US in the hands of every resident and faculty physician, see link. The top three players in this market is Philips with the Lumify, which seems to have the most comprehensive set of features especially OB/GYN measurements and templates, the GE unit, and the Butterfly. Butterfly is somewhat of an outlier as it has a subscription model for its usage and uploads images in their cloud. Pricing is between $6k and 2k for these units. A major challenge with these devices is how to archive any of the images that the physician wants to keep as they have to be properly identified with metadata to make sure they end up in the correct patient folder.
EMR vendors are pushing solutions to upload these directly into their systems, which is a mistake, images belong in an enterprise image management system together with all other images, however, these archives, often a VNA,  have been slow to adapt to the specific workflow requirements for these devices, even though IHE has already put a specification out defining on how to do this.

4. In addition to POC-US, there is POC-DX, POC-CT and POC-MR. The POC-DX, also known as the x-ray portables, have been around for a long time, they are mainly used in the OR, ER and ICU’s to provide bedside diagnostic x-ray.

Cute portable for kids
These portables use digital x-ray plates, which are wirelessly connected so that the images can be transferred automatically from the plate to the portable console for processing and QA and then wirelessly sent to a PACS for physician and radiologist viewing. The DR plates are getting less expensive, battery life is getting better, but they are still rather heavy, and one has to be careful to protect them from body fluids as many are not 100% sealed.

Fuji showed a flexible sensor detector which brought the weight of the

Most innovative product IMHO:
flex detector
plate back to a mere 4 lbs. Except for developing countries, where price is still a big determinant, DR is now replacing CR at a rapid pace. Sedecal showed a “ruggedized” version of its portable unit which can be transported in a “box,” has big wheels and is mainly used in the field by specialized users such as the Red Cross or the military in areas of conflict and natural disasters.

Looks like a CT,
moves like a portable
POC-CT has grown up as well. These CT scanners have evolved from a “CT on wheels” to truly portable units and can be moved around as easily as portable x-ray units. These have built-in radiation screening as part of the gantry and a lead flap in the front and back to screen any additional radiation.

my second most
 innovative product choice
The POC-MR was a newbie at the show. It is still subject to regulatory approval which can be expected later this year. Its application is somewhat limited due to its low field strength (.064T), but the advantage of the low magnetic field is that there are no issues with shielding, as a matter of fact, they were scanning in real-time in the booth. The images are very noisy but new advanced image processing and AI can improve the image quality up to a point that they are usable for the application needed.

5. Photographs can assist in diagnosis. Photographs can provide important contextual information and can be taken by providers as well as patients using a camera or smartphone. There are clinical and technical challenges to recording and managing these pictures. The clinical challenges include privacy and how to deal with sensitive photos, including the definition of what constitutes a sensitive photo. Technical challenges include security as well as how to capture the appropriate metadata such as patient information and body part. 
Good example showing photo and image
There are two working groups established that are supported jointly by HIMSS and SIIM to address these issues, the Photo Documentation Workgroup dealing with the clinical and technical issues and the Data Standards Evaluation Workgroup dealing with analyzing the existing standards for nomenclature related to body part and anatomic region. White papers can be expected from these workgroups in the near future.

Still need huge glasses but effect is amazing
6. Virtual Reality (VR) is moving to Augmented Reality (AR). VR has been somewhat of a niche application, mostly used by surgeons to prepare for surgery as it can show true 3-D models of the organs using CT or MR source
data. VR has always been a little bit disjunctive from the real patient as there has been no real direct connection between the actual subject and the images that are shown in a 3-D space. AR is changing that as there is a direct connection between the patient and the image created by the 3D. For example, a surgeon can look at the patient through his special AR glasses and see the synthetic image super-imposed on the body part of interest. Again, VR and AR are somewhat of a niche application but it is quite fascinating and really cool to be able to have “x-ray vision” and look inside a body and see its organs from different angles and perspectives, which should be of great help to surgeons. A great example of how radiology supports other specialties.

7. Monitor management for home reading is a challenge. Imagine that you want to read from home, and for your worklist and reporting you use a laptop computer. One would typically have two medical grade monitors, but that could be three or four as well. The good news is that most radiologists are starting to learn that using a medical grade monitor is a requirement for reading anything CR/DR and certainly mammography.
Monitor management black box
This means that the monitors are calibrated to show each individual pixel value into a greyscale value that an observer can distinguish so as not to miss any subtle changes in pathology, and they are typically managed remotely including the possibility of keeping those calibration curves in case the quality of the monitor display was challenged in a potential malpractice lawsuit (which is not uncommon). 

However, when trying to connect those multiple monitors using a standard windows PC, the hanging protocols, i.e. where the images are displayed is challenging and it might vary upon rebooting the PC. Therefore, one might use one of those small “black boxes,” which has a video board inside and a controller that can remotely connect to the calibration management software. It manages the display order so that it is consistent any time a radiologist connects his or her laptop again.

MRI with built-in recliner
8. New open MRI’s are being introduced. There have been open MRI’s for a long time, the advantage is accessibility to the patient which is especially important when doing surgery. Other reasons for doing an exam in an open MRI might be for patients who are claustrophobic. Lastly, if a patient has a condition that only shows up when he or she is standing or sitting, i.e. if there is a need to show the load-bearing there is now a unit that allows the patient to keep on sitting. Another example of how some of the common devices are being created for niche applications.

9. 3-D printing is maturing. The novelty of 3-D printing is somewhat over compared with last year’s RSNA, but there was still quite a bit of interest,
Amazing detail
and several vendors displayed some amazing examples. Also, since 2018, the DICOM standard includes the so-called STL (stereolithography) file format, which is commonly used by CAD software. This format can be used to send to 3-D printers, but also can be encapsulated into a DICOM file, i.e. with the typical DICOM header, the modality being “M3D,” similar to the encapsulated PDF files. It can then be managed on a PACS archive such as a VNA and added to the study, e.g. the CT, and be used to reprint if so desired. There is no question that for surgery planning for difficult and rare cases, this is a great tool that is becoming available.

Looking for volunteers!
10. In case you missed the friendly ladies at the RAD-Aid booth, you can website and sign up as a volunteer. I have been very fortunate to have first-hand experience with the impact that you can make by teaching in developing countries and supporting your peers in your area of expertise. Remember, you don’t have to be a radiologist teaching interpretation or IR, but there is also a major need for people teaching basic x-ray as well as CT, MR, US, and even how to procure and maintain systems, how to manage a department, and how to troubleshoot image quality and technical problems.

Excellent Tech support built in
The good news is that some of the vendors are incorporating features in their products that kind of “guide” a technologist through a procedure. A good example is the Carestream CR console that shows how to expose an extremity and make sure to use collimation, something that is obvious to anyone taking an x-ray in the developed world, but is often overlooked in these emerging markets. I can promise you that volunteering can not only make a major difference in the lives of the ones you touch and interact with, but you’ll become a different person.

In conclusion, this was another great year, there were some great talks, my favorite was “AI in
Cabs and Ubers lining up
for drop-off
developing countries,” where I think it can make a major impact due to the limited resources and lack of training. Some African countries have fewer radiologists than there are in my hometown, and therefore AI can be a major help. Remember, in those cases we are not concerned if there are a few percentage points gained in specificity or sensitivity, if you start with “0,”anything is pretty much a gain.

However, regarding the state of AI, I have never seen so many vendors without FDA clearance promoting solutions based on limited datasets from only a subset of the populations, for example how valid is an AI algorithm based on a clinical study in China to a population in a downtown US city where the majority is African-American?

I am curious to see the progress made by the same time next year, if I missed you this time, I hope to see you next year!