Steve Holloway, from Signify Research explores the daunting challenge of navigating the road to Enterprise Imaging.
Cloud technology is transforming how we live and work today. For healthcare providers undergoing long-term digitalisation, the potential of cloud technology resonates, yet the complexities of adoption are daunting and difficult to navigate. Nowhere is this more evident in healthcare than imaging informatics.
A front-runner of healthcare digital innovation, the imaging sector has a complex legacy of on-premise, siloed, best-of-breed applications that interact with and influence every point of the care continuum.
Many providers have taken the positive steps of embarking on an enterprise imaging strategy, federating imaging service line applications, centralising data management and transforming access for diagnosticians, care givers, and patients.
Progress on this mission has been challenging however, in part due to an over-reliance on aging on-premise applications and limited availability of alternatives.
Today, a new generation of cloud-based enterprise imaging solutions is emerging, offering a tangible route to cloud. In this paper, we’ll identify the key characteristics of this new generation of cloud-based products and outline the key drivers and barriers to their adoption.
Further, we’ll describe the long-term transformative power that cloud offers for enterprise imaging and the future of healthcare provision, providing our view on the key considerations for providers navigating cloud adoption for enterprise imaging.
Dr Gareth Davies describes the massive impact the COVID 19 pandemic had on elective cross-sectional reporting, reducing output to almost zero. Here he reflects on how the drive for innovation and the motivation to think differently led to a better teleradiology service for both patients and staff.
The pandemic will certainly define us as an organisation. A period of uncertainty, business survival, the protection of our staff and their livelihoods and a readiness to provide a clinical service our patients rely on.
Let’s go back to the 1 January 2020. It was a time when the UK’s radiology reporting capacity was at a tipping point, backlogs of unreported examinations were in the thousands, demand for imaging services was constantly increasing, and more and more patients were being scanned. Just in one single day in that month, Telemedicine Clinic (TMC) reported over 1400 elective cross-sectional scans to its NHS customer base.
Wind the clock forward to May 2020, and during the midst of the Coronavirus pandemic a grand total of 11 plain films were reported in a whole week.
TMC’s business is teleradiology, a service that underpins delivery of clinical services to the customers it reports for. Take away the need for outsourcing by having to stop elective scanning and there is no need for teleradiology. Take away elective scanning and the backlogs built up over time can be cleared. The reset button had been pressed and no one knew what was going to happen next.
TMC employ over 300 radiologists, with over 50 radiologists working in the emergency section. The recovery for this section was quick with demand returning to normal volumes after 3 months. The recovery of the elective service has stalled in line with countrywide lockdowns but is now about 60% and getting busier.
So how did a company that had 50% of its business disappear overnight survive? The simple answer was innovation!
The first thing TMC did was to call on its European based radiologists, staff, and management teams to team up to provide an unrivalled knowledge-share hub. Coronavirus imaging from hospitals all over the world was collated to provide real-time COVID reporting best practice as the world started to understand the virus more. In addition, top thoracic specialist radiologists from Europe who had already experienced COVID radiology were called to report cases for NHS hospitals. A new “24/7 COVID response” reporting team was established in less than 2 weeks.
On the back of our experience with the 24/7 COVID Response service, the TMC Academy used our reporting experience and best practice from other nations experience to create two COVID-19 online reporting modules on the TMC Academy platform and made these free to all to view and learn from.
Our next step was the deployment of the TMC Platform for our NHS customers. Where TMC had a contract in place with a Trust who also had reporting radiologists collaborating with TMC, TMC enabled the radiologist to work for their hospital using the TMC infrastructure and IT, free of charge such that the radiologist could work remotely reporting their cases, where home reporting was not available at that time. Driving down costs to our customers in the future is a focus of TMC.
TMC is proud of its recruitment process for radiologists. Our traditional model was to invite potential colleagues to our head office in Barcelona, to undergo a series of interviews and undertake test case examinations specific to their subspecialty. What do you do when you need to recruit radiologists in a period of complete lockdown, with the inability to travel even a few miles? You challenge your teams to virtualise a 3-week induction/test period of course! This was completed again using the online TMC Academy platform to make sure all radiologists were fully vetted, interviewed, examined and quality-assured to comply with our standards and strict working regulations required to support the UK market and the NHS.
Prior to the pandemic, TMC were aware of a growing need for acute reporting services ranging from neuro MRI ad hoc reporting to Emergency CT daytime cover to sub-specialist short turn around reporting. One of our major ambitions during this period was to innovate more integrated clinical care and break the traditional concept of teleradiology and the clearing of backlogs and night time on call. TMC are good at elective reporting and using UK and European based radiologists. TMC are also good at UK overnight Emergency CT reporting from wide awake UK and European radiologists who have moved to Australia. However, there is a mix of requirements that TMC did not fully cater for and the NHS desperately requires. From conversations with customers, it was clear that elective reporting, although destined to return with a vengeance, was not the priority. The main driver in fact was a mixture of acute and semi-urgent work so, from this, The TMC Hub and TMC Oncology concepts were created.
Any time of the day or night, a clinician, radiographer, or radiology manager can call TMC to discuss scanning a patient. These can be emergency patients in the day or night, they can be acute inpatients who simply need that next step in their pathway or to be discharged safely, or perhaps just a routine scan which feels urgent. The TMC Hub can help put the patient on the right pathway for their care, anytime day or night, Monday to Friday or a weekend. TMC’s customers love the new HUB concept, it provides a real safety net that they can contact us to get a patient scan completed, all within the hospitals set guidelines.
Last but not least, during the pandemic, TMC has had the opportunity to establish a dedicated team to evaluate the plethora of AI products on the market and implement products which we believe will improve patient care. Through stringent evaluation, TMC now has a number of AI products in place to assist its radiologists in making a clinical report. For the emergency section, AI now looks at all CT PA examinations for pulmonary embolism (PE), subtle C-spine fractures in trauma scans and intracranial haemorrhage in CT brains. For elective services, the AI software looks for PEs in all CT examinations that involve the thorax as soon as the examination arrives in the TMC PACS. In our new low dose CT thorax reporting for the NHS lung screening / lung health check service, we are using nodule detection and automated reporting to the requirements of the NHS QA standards for such a service. And new to TMC’s repertoire is a novel service, bringing AI to its clients without them knowing it. Through TMC’s IT infrastructure, our AI solution can look at ALL images in a customers PACS to identify incidental PEs, assign them to a TMC radiologist for immediate reporting which is flagged to the clinician team on-site in real-time. A scan that could have waited 3 weeks for reporting with unknown downstream costs to the Trust. AI will not replace radiologists, but it will improve radiology workflows, something which TMC can help clients do.
With innovation comes benefit, a benefit that can be passed on to our customers in terms of reduced costs for delivery as well as reduced costs further down the patient pathway. Innovative services such as the TMC Hub or the TMC Oncology service will give clients the confidence they need to get a scan reported first time by the most appropriate and qualified radiologists.
Teleradiology and outsourced radiology are looked upon as a cost to the NHS which needs to be removed. With over 90% of NHS services relying on overnight emergency services being delivered from the independent sector, it is hard to see how this will change any time soon. Instead, looking at how teleradiology can help underpin service delivery, provide the AI analysis and expertise, provide the IT network to telework over international borders whilst using capacity from Europe to add to the overstretched UK workforce, the question should be how can we integrate more with our providers to deliver value-driven innovative healthcare to all people.
About Gareth Davies
Dr Gareth Davies, UK Medical Director Head and Body Section (Full time employed) Dr Davies has 18 years’ experience as a Consultant Radiologist in the South Wales NHS prior to joining TMC in 2019. He has a specialist interest in interventional and oncological radiology and held various national roles including the Regional Specialty advisor for training in Wales (Royal College of Radiologists), a member of the Clinical Radiology Specialty Training committee (RCR), Lead Radiologist and Lead QA of the Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP), Associate Medical Director of Cancer Diagnostics and the Clinical Lead of the Early Cancer Diagnosis Programme, Wales Cancer Network and member of the Clinical Advisory Panel for CRUK. Since Joining TMC, Dr Davies has been involved in helping form TMC Oncology as well as working within the UK Business Unit to develop a more clinically integrated approach to telemedicine with the NHS forming the TMC Hub concept.
Jane Rendall examines what is needed to make large scale NHS imaging programmes work.
Region-wide NHS procurements for diagnostic imaging are becoming increasingly ambitious in their efforts to support faster diagnoses and better care for millions of patients. They are a means to reduce variation, to enhance equity, to change how healthcare professionals access, analyse and report, and they can facilitate new ways of working collaboratively across large geographies.
But what is the key to making these multi-trust projects successful and what lessons can be shared?
I’m fortunate to have worked alongside several NHS consortia that are doing some extremely impressive things. These are some of the key things, in my opinion, that can drive success.
1. Think multi-ology rather than radiology
As an early discipline to digitise, radiology has traditionally been the home for digital imaging in the NHS. But modern programmes are about realising a vision to bring imaging together from across the whole of healthcare.
An integrated multi-ology approach to imaging means a much richer information resource to augment a report, and much more information at the fingertips of many more professionals, and indeed patients themselves.
Taking what has become known as an “enterprise approach” to imaging strategy isn’t a new idea, but it needs to be recognised and put into practice if large scale programmes being embarked on are to be successful.
2. Enterprise level responsibility and strategy
To move to an enterprise approach effectively, responsibility needs to be taken at the enterprise level. This might mean lifting imaging technology out of the radiology department and entering it as an IT or digital service.
There will probably be a range of internal funding and management complexities to be navigated in the process, but this will mean that imaging can sit at the heart of digital strategy and that information vital to patient care can flow more freely.
It will also mean that radiology imaging system managers will not be burdened with an isolated task of managing data from multiple additional departments.
Sensitivity needs to be shown to people who might be concerned about losing niche functionality, and mechanisms put in place to maintain the tools they need.
A higher-level strategy that has the buy-in from chief executives, chief information officers, chief clinical information officers, finance directors and others, and that is clear on what organisations involved are going to achieve, must also be established.
The same “top brass” must also be willing to provide strategic sponsorship, leadership, and decision making at necessary points. Roadblocks will inevitably be encountered as large-scale programmes are conceived and executed. Strategic decisions will be continually needed along the way to overcome anticipated and unforeseen challenges, and those decisions cannot be taken in the ranks. When authority is provided from the top, a mandate can be given to allow the willing entrepreneurial people delivering great things on the ground to drive forward the initiative.
3. Managing complexity at a regional level
Elevating imaging to the enterprise level of a trust is one thing, but how can this be effectively done across an entire region? Some of the programmes I have worked with have as many as seven, eight, or even nine trusts involved.
One answer is to contract under one participating organisation which in turn has memorandums of understanding in place with all of the others. There are proven mechanisms that can work, but contracting is just one consideration in a programme that involves navigating everything from data sharing to the allocation of human resource.
That is why authority provided by strategic regional board level sponsors is key; if this is a priority for CEOs in a region, then it becomes a priority for others to work through some of these significant challenges.
But equally key is establishing appropriate governance structures, and putting the right people in place to manage delivery. Successful programmes that I have seen are driven by a type of “civil service”: people who do the job, who ensure strategic papers are passed through necessary boards and who can ensure the right things happen at the right time with the right people.
As a supplier, I think we must have faith in our customers and their ability to do this effectively, but again it comes back to having the right strategic objective with appropriate milestones, and a full understanding of how decisions affect different people throughout the organisations involved.
4. Finding the champions – and not just “yes people
Finding champions early is extremely important. For example, artificial intelligence is an area which is of huge interest. But even something as exciting as this will go nowhere without a champion who is really looking to push the idea within the customer organisation; someone who can talk to people and engage, energise and inspire them. Champions must have a level of power to drive the conversation and they need to have aligned goals.
Once the champions have been found, it’s important not to take them for granted and to show them appropriate recognition. This might mean helping to elevate their voice as an influencer or thought leader in the media, for example, or nominating them for awards for which they are deserving.
Successful programmes need more than “yes people” though. You also need champions who are prepared to challenge. That’s when you really start to have useful dialogue. You want people who spot the problems before they happen, people who know the operation and who know their business. We need the people who really understand technologies and what we can do outside of the norm, so that when a problem requires an unconventional solution, the art of the possible can become reality. As a supplier, that sometimes means knowing when to take an anti-sales approach and to bring the technical experts to the table.
5. Work with the exiting supplier
Exiting suppliers have a significant role to play in smooth transitions, especially for areas like data migration.
It can be challenging for a supplier that might be disappointed to be the outgoing party. But it is important for that supplier to consider long-term relationships and their reputation in the market.
Where we have exited in the past, we have made sure we have delivered a professional, timely, responsive approach to that exit. It is a long-term game and a small world in NHS technology. In 5 or 10 years we might well be back there.
Programmes of this scale do not happen overnight. That’s not to say that given the momentum building in the NHS for regional diagnostic approaches that accelerated approaches cannot be developed. But with so many parties involved, things can take longer than a lot of people might predict. Be patient and maintain your determination.
7. An open mind
Customers can often benefit from approaching procurements with a truly open mind. Sometimes people can have a preconceived idea of what the solution needs to look like before they go to market. Sometimes getting real value from the market means allowing competitive suppliers to come up with the innovative solutions to meet the requirement.
Some suppliers in the market have learned lessons from similar projects that have gone before, lessons that they are often more than happy to share. And they may have visibility of new technology coming down the line that the contracting organisation isn’t necessarily aware of.
Intelligent customers know their strategy, they know their organisational needs, the requirements of their people and they know their business inside out. But they also know that there are opportunities to be educated at times. There might be ways of solving problems that they hadn’t previously considered. And in some major procurements we have seen the end solution looking very different to the original requirement.
Establishing and communicating a central vision is crucial throughout all of the above. This must be bought into from the most senior CEO to the user on the ground. Given the pressures faced in NHS diagnostics, and the opportunities for transforming patient care that come from a regional approach to imaging, the vision behind many regional initiatives is extremely powerful.
About Jane Rendall
Sectra UK’s Managing Director, Jane Rendall, joined Sectra in 2010. Located in our UK and Ireland headquarters in Hertfordshire, Jane has a strong clinical background and is on a mission to drive innovation through collaboration and evolve healthcare IT to more cost efficient and adaptable platforms to improve the effectiveness of patient care across the UK and Ireland.
Jeroen van Duffelen proposes a five-step programme for adoption of artificial intelligence in clinical practice.
Adoption of medical imaging AI is about getting your hospital or screening programme ready to implement the right solution for a clinical need. Running into speed bumps along the way is common for early adopters. How do you define the needs, budget, and outcomes? Which boxes should you check when selecting vendors? How do you manage internal stakeholders? The adoption curve is steep. Luckily, you don’t have to climb it alone.
Drawing from our experience deploying AI in clinical practice and lung cancer screening, I’ve designed a five-step guide to streamlined adoption. If you’re looking to adopt artificial intelligence but don’t know where to start, these actionable tips and advice will see you through. For the video breakdown of the steps, watch this presentation from ECR 2020.
Where do you start working with AI? First, look away from all the solutions out there, and focus on your organisation. Bring together all the stakeholders into a project team that includes the sponsor, if applicable, IT and legal representatives. Involving them from the beginning will expedite the process.
Start with defining the challenge you are looking to solve, or the specific clinical question that is relevant to your workflow. Some hospitals are looking to experiment with the technology, while others aim to solve a particular issue. Over the past years, I have seen the latter getting more out of AI, which is why my advice is to start from a clinical challenge.
When considering this challenge, make sure to already determine your expected outcomes. When is the adoption a success? Are you aiming to have an AI solution in use? Should it apply to a certain patient population, or yield specific results like time or cost savings?
Also, although it may seem early, this is also the stage to organise a budget dedicated to the AI solution. The size of this budget should relate to the cost or time savings a solution is expected to bring. Both the amount secured and its source will impact the next steps. For example, it will guide you to look for PhD researchers versus seeking a vendor that offers a mature solution.
The AI in healthcare space is widely populated; a Google search or a look at the list of vendors at the RSNA can confirm that. To weigh the existing options for your scope, do your (desk) research using this high-level checklist for each solution:
How was the AI solution validated?
It is important that the claim that the AI solution has validated covers the use case you identified in the previous step. Take the time to understand if the manufacturer has done studies confirming this claim.
How does it integrate into the workflow?
Try to get a feel of the amount of effort needed to add an AI system into your workflow. A good practice is to start with an AI solution that is easy to integrate with the current workflow and IT infrastructure. Workflow integration is of utmost importance for the radiologist; in this article, we explained why that is and how it works.
What regulations does the solution fulfill for use in clinical practice?
Commercialising medical devices requires a CE Mark in the EU and an FDA clearance in the US. Note that local regulations may apply to different countries. Again, pay attention to which claim is covered by the acquired certification.
By this stage, you should have narrowed your search down to a few vendors. This is the moment to go in-depth into the workflow and test if a specific solution is a good fit from both a clinical and a technical standpoint. A well-integrated AI system should not create hurdles for physicians, such as requiring them to leave their workstation to upload studies. It should further blend within the existing IT infrastructure.
There are two checks that are vital to make the right choice:
Validate the accuracy
Legitimate vendors would have done a study and can provide a clinical background for accuracy. To know if the solution is good at performing the defined task for your organisation, ask questions about the datasets used to develop and test the AI solution.
There are three datasets required to build an AI model: a training dataset, a validation dataset, and a test dataset.
The test dataset is the most relevant to look at because it is what the accuracy is based on. The performance on this dataset should be applicable to your hospital, with its specific protocols, type or number of scanners, and patients. To achieve this, the test set must cover the patient population your organisation serves (e.g. types of patients, comorbidities distribution, etc.). Thus, inquire about the specifics of the test set and the performance of the AI model on this dataset.
Secondly, you may want to know what the size of the training dataset is and how it was labelled. Both quantity and quality are important to train an accurate AI model. Labeling the data should be done by experienced radiologists, preferably with multiple readers per study.
Check the regulatory compliance
In Europe, medical device classification is divided up between risk Class I, Class IIa/b, or Class III. If looking for a solution for clinical practice, be wary of Class I medical devices. The new Medical Device Regulation, which will come into force in May 2021, will require many AI products currently classified as Class I devices to update their classification. For instance, software that supports diagnostic decisions should fall under Class II at a minimum. For more guidance on the new regulation, read our recent expert piece.
Apart from the regulatory approval, check if the vendor also has a quality management certification (e.g. ISO 13485). Reviewing the data processing policy and the cybersecurity measures in place will further help you understand if the AI company is going the extra mile in regard to safety.
A bonus tip for the choosing stage: do a reference check. Ask other organizations how they are working with the AI solution you have chosen. You may get the insights you need to make the final decision.
Approving the chosen solution internally requires the involvement of and coordination between IT and PACS administrators, procurement officers, physicians, often also privacy departments and legal officers. If you have a project team in place since the first step, you should be well on track.
To move forward and avoid delays, assign an internal AI champion responsible for driving the project. This may be an executive sponsor, a budget holder, or a department manager. One of my learnings from past deployments is that the risk of failure is high without a person fulfilling this role. What I have further learned as vendors is the importance of empowering the AI champion, by providing the necessary information and documentation in a timely manner.
Furthermore, make sure end users are trained to use the new medical device. If they don’t benefit from it, the impact of the AI solution will be limited. Additionally, setting up a feedback mechanism with the AI vendor from the get-go will help improve the AI product.
5. Deploy (& evaluate)
All the paperwork is signed – well done! To make the deployment work, create a clear project plan, including actions, timelines, and owners. Depending on the type of deployment – on-premise or cloud-based – different actions will be needed. As outcomes, set the deployment and acceptance dates, make agreements on the service levels, fixes, and upgrades, and discuss post-market surveillance.
The initial or trial phase of using the AI solution should show if it answers the problem you were trying to solve. It is a good moment to revisit step one and start evaluating the results to decide if you will continue using the solution.
A common question I get at this stage is: “Do I need to do a full clinical study?” The answer fully depends on the purpose of using the product. It is necessary for research, but not for other use cases. What matters is validating that the AI solution is adding value to your clinicians and their patients.
Make it better
AI adoption does not end with deployment. Service and maintenance are essential, and their quality often a differentiating factor between AI vendors. The implementation process usually acts as a good test for the AI companies fulfilling their promises and being prompt when handling requests.
Beyond these five steps, you and your organisation play a role in improving the chosen AI solution through valuable feedback and feature suggestions. The collaboration between humans and software allows us to achieve much more than humans would on their own. If done right, it can be transformative for patients.
Jeroen van Duffelen is COO and co-founder of Aidence. Jeroen’s entrepreneurial spirit led him to teaching himself software engineering and starting his own company commercialising an online education platform. He then tried his hand in the US startup ecosystem where he joined a rapidly scaling cloud company. Jeroen returned to Amsterdam where he ran a high-tech incubator for academic research institutes, it is here Jeroen first got his taste for applying AI to healthcare.
The Revd. Canon Dr. Mike Kirby, Chair of the BIR Oncology and Radiotherapy Special Interest Group, has a wealth of experience as a senior radiotherapy physicist, working on national guidance, developing clinical practice and teaching radiography students. As if this doesn’t keep him busy enough he has also taken on the role of Canon Scientist at Liverpool Cathedral where he is working to encourage dialogue and discussion about science and faith. Here he explains what the role involves.
I began work in the UK’s National Health Service more than 30 years ago, as a Radiotherapy Physicist at the Christie Hospital, Manchester UK. Alongside my routine clinical work, my main research interest was in electronic portal imaging and portal dosimetry. I then helped set up Rosemere Cancer Centre in Preston, UK from 1996 as deputy Head of Radiotherapy Physics and Consultant Clinical Scientist there. During that time I contributed to and edited national guidance documents such as IPEM Reports 92, 93 and 94 and the multidisciplinary work, ‘On-target’.
My work moved back to the Christie in 2007 and as Head of Radiotherapy Physics and Consultant Clinical Scientist for the Satellite Centres, I helped to lead their development in Oldham and Salford as part of the Christie Network. My research and development work has primarily focused on electronic portal imaging, developing clinical practice and equipment development.
More recently my focus has been on teaching and learning for radiotherapy education as a lecturer (Radiotherapy Physics), especially using VERT, for Radiotherapy programmes in the School of Health Sciences, Liverpool University; but always with a focus on the wider picture of radiotherapy development having served on both IPEM and BIR committees throughout my whole professional career.
Alongside my scientific work, I am a priest in the Church of England; having trained and studied at Westcott House and the Universities of Cambridge and Cumbria, I hold graduate and postgraduate degrees in Theology.
My ministry has mainly been in the Cathedrals of Blackburn, Chester, and Liverpool (Anglican) where I was Cathedral Chaplain. I have recently (Feb 2020) become a Residentiary Canon of Liverpool Cathedral, with the title of Canon Scientist the primary aim of which is to encourage dialogue and discussion about science and faith.
I am a member of the Society of Ordained Scientists and have given numerous talks on Science and Faith to schools, colleges, churches and other institutions. These have included organising lecture series with world renowned speakers at Blackburn (2016) and Chester (2018) cathedrals; a third series was delivered at Liverpool Cathedral in May 2019, and a fourth series is planned for May 2020.
My role is to consider all sciences (physical, clinical, social) in ecumenical and multi-faith environments. So I will look to work with initiatives already developing in other Christian traditions, other faiths and secular organisations to discuss current challenges, such as climate change, medical ethics, health initiatives and information for cancer, dementia and mental health issues etc..
My work will be part of the clear faith objectives of the cathedral as a place of encounter for everyone, through events and initiatives within the cathedral, but also beyond. This will include services focusing on health issues and pastoral challenges (such as bereavement and loss); events engaging with science, its wonders and challenges; fostering further relationships with local and wider communities on science and healthcare education, and with academic and scientific institutions too; encouraging scientific and ethical engagement with schools and colleges, as I have done so previously in both Chester and Blackburn dioceses.
I will be encouraging Christians and Christian leaders to understand science and engage with it more, alongside other national projects such as the recently announced ECLAS (Engaging Christian Leaders in an Age of Science) project of Durham and York universities and the Church of England. As a self-supporting minister (one whose paid employment is outside of the church), I will also look to encourage and highlight the tireless work of many others who already do this within the diocese and the wider national church.
Within all of this, I have always seen my vocation as being one within God’s service, for all people, with my work for cancer patients being right at the heart of it.
If you have any questions for Mike, you can send him an email at firstname.lastname@example.org
Mike is the co-author of the international student textbook on On-treatment Verification Imaging: a Study Guide for IGRT, through CRC press/Taylor and Francis with Kerrie-Anne Calder. They are both contributors to the updated UK national guidance on IGRT due out in 2020.
Mike, with the support of the SIG, has helped to organise a range of events for radiographers, physicists, dosimetrists, radiologists and oncologists. See the full programme here
The Unofficial Guide to Radiology won the BIR/Philips
Trainee award for Excellence in 2015. Tom Campion, radiology trainee at Bart’s Hospital, London and Valandis Kostas, Senior Radiographer from Guy’s and St Thomas’ Hospital reflect on the latest addition to the series which focuses on chest x-ray interpretation and is designed to support professionals and students.
A follow-up to the Unofficial Guide to Radiology, and part of the Unofficial Guide to Medicine series, this new book The Unofficial Guide to Radiology: 100 Practice Chest X-rays, with full colour annotations and full X-ray reports has at its heart the inspiring idea that the development of educational resources should be driven by those who use them. The result is a fantastic resource for reporting radiographers, medical students, junior doctors in any specialty, providing a comprehensive and practical approach to chest x-ray interpretation.
Right from the start, the book’s cover is self-explanatory and is easily perceived to be about chest X-ray interpretations. The 100 chest X-ray cases are presented in a test-yourself format, with the images and case history presented on one page and the interpretation and report on the next.
The cases are separated in three coloured divisions: Standard (orange), Intermediate (purple) and Advanced (blue). The first page provides the reader with a short clinical indication followed by the associated chest X-ray in high quality, all in one page. The second page then evaluates the technical features, again using a colour code scheme which is then diagrammatically presented on the same chest X-ray, but on a smaller scale. It may be coincidence that the orange, purple and blue technical features can also be perceived as standard, intermediate and advanced technical points to look out for from a radiographer’s perspective. Finally, there is a short but precise summary demonstrating a report of the chest X-ray followed by further management for the patient.
The image quality is excellent in comparison to most other available textbooks, with crisp full-page images allowing the detail of the images to be explored – crucial in the days of PACS when every possible abnormality can be magnified a hundredfold.
Each ‘answer’ page has a consistent format, embedding a sensible interpretation pathway, and a clear layout highlighting both normal and abnormal findings. The consistency, and the detailed and comprehensive annotations, allows the reader to build up an idea of ‘normal’ over the course of the cases, continuously reinforcing important structures to check on every radiograph.
The multidisciplinary approach to development also comes through strongly, with suggested first management steps in response to each radiograph placing the interpretation firmly in the pragmatic clinical world. However, the ‘reporting’ style employed also develops familiarity with the language of radiologists; if this can sometimes seems overly formal or formulaic, it serves a purpose in ensuring that clinicians and radiologists are on the same page.
The clinical cases provided are realistic and are what you expect to find whether in Accident and Emergency and/or outpatient, GP clinics. From pathologies to pneumothoraxes, fractures to line insertions, most scenarios are covered in this book.
Valandis Kostas strongly recommends this book to all grade and advanced radiographers. He observes that the book provides the patient pathway link from clinical presentation to radiology, to treatment and type of follow up imaging required i.e. CT and/or chest clinic referral. The layout enables understanding of the acquired chest x-ray, vital for best practice.
He particularly applauded the section on quality of the chest X-ray, using the similar 10 point image quality check radiographers use in their clearance of X-rays they undertake. Patient I.D, rotation, penetration and inspiration are a few examples. Furthermore, the case layout educates radiographers the importance of these checks to aid image interpretation for diagnosis whilst encouraging learning about chest pathologies. This will eliminate the repetitious perception of the chest X-ray and it will encourage radiographers to maintain high quality chest radiographs for accurate diagnosis and reduce false negatives and false positives.
The clinical details provided in the case vignettes are of a level of detail that surpasses most of those seen in clinical practice; hopefully, the detail provided here will also serve to demonstrate to clinicians who read the book how fundamental these details are, and serve as a resource on helpful requesting as well as interpretation of chest radiographs.
An important area for radiographers and radiologists that is not covered in as much detail is the inadequate chest x-ray, and perhaps the book could be improved by including a few examples of misses/near misses from poor quality radiographs in order to educate readers on when a repeat X-ray is required.
Tom Campion, trainee radiologist would happily recommend the book to anyone whose job involves X-ray reporting as it delivers a solid foundation in interpretation skills and serves as both a thoughtfully structured introduction to the beginner and a handy reference to the more experienced.
Both Valandis and Tom felt that the book would make a great app or online tool in the future.
Historically, physicians have been both radiologist and radiation oncologist, and diagnostic and therapeutic roles have sat comfortably with one physician.
Dr Richard Simcock argues that times have now changed and there is a strong case for a radiologist AND a radiation oncologist in the planning room.
Thor Stenbeck is a hero of Swedish physics. Soon after Röntgen’s first X-ray image Stenbeck could lay claim to the first documented therapeutic use (locating a bullet lodged in a skull). Later he successfully irradiated skin cancer with the first documented fractionated therapy. Stenbeck is our first example of a physician becoming both a radiologist and radiation oncologist.
Thor Stenbeck at work
The model has been endlessly repeated. Throughout the 20th century the therapeutic and diagnostic possibilities of the magical rays were supervised by key pioneers. One of Britain’s greatest examples was Ralston Patterson. Patterson trained in radiology in Cambridge, South Africa, Aberdeen and the Mayo Clinic before leading Manchester’s Holt Institute and trailblazing for standardisation in the medical physics of therapy.
Patterson was an early President of the Faculty of Radiologists, later transformed into the Royal College of Radiologists (motto, “From Rays, Health”). The Royal College still accredits both radiologists and radiation (clinical) oncologists—but the world has moved on.
Today’s radiotherapy maximises therapeutic ratio by using the best of radiological imaging to accurately identify a malignant target and the organs at risk (OARs). It then uses image guidance to ensure that the bullseye of the target never drifts from the treatment beam. As technology develops so does the ability to identify and potentially spare new OARs. At the recent BIR Meeting on “Diagnostic Radiology for Advanced Head and Neck Planning” delegates heard data on “new” OARS such as cochleas and carotids as well as reviewing how to identify emerging OARs in the swallowing musculature on high-resolution CTs. The meeting buzzed with talk on MRI and PET fusion in the radiotherapy planning process as well as diffusion-weighted MRI and nuclear medicine in diagnosis.
These technologies are figuratively and literally decades apart from the images Patterson used to guide treatment and yet we cling to one relic from the age: the dual role of radiation oncologist as radiologist. This is a nonsense.
The interpretation of imaging should be performed by those most expert, and in almost every case that will be the experienced cancer radiologist. Despite this it is usually the radiation oncologist who defines the visible tumour target ( or gross tumour volume (GTV)) in radiation planning. One assumes therefore that the radiation oncologist is trained in radiology? Sadly not.
It is an embarrassing fact that the post-graduate training of the UK clinical oncologist (as specified by the RCR curriculum ) requires no training or examination in radiological anatomy nor radiology. There are examinations in statistics and cancer biology but no expectation that trainees should be formally taught how to use the imaging that they use as the eyesight of their weapon of choice. Clinical oncology trainees may however be examined in the design of a radiotherapy bunker—a fitting metaphor for this silo thinking.
Elsewhere in the world the situation is not much better. Neither the US nor Australian training schemes mandate any radiology training (although the Royal Australian and New Zealand College of Radiologists (RANZCR) are considering it). In Canada at least a 4-month radiology attachment is expected (a model followed by some UK centres e.g. Glasgow) but this is not long enough to learn a radiologist’s craft. A recent study identified 84 radiological competencies as a minimum for radiation oncologists. We need to change the model; not “Jacks of all trades” but Masters of one.
We must bring together radiological knowledge and harness it to an oncologist’s expertise. Radiologists remain essential in diagnosis, staging and response assessment. Radiation oncologists determine clinical target volumes and critically assess the final plan. The two come together to identify tumour targets and OARs; radiologist and radiation oncologist in the same room but not the same person.
The BIR meeting showed us how far we have come (and can go) in head and neck radiotherapy.
Delegates at the BIR Head and Neck event, November 2014
It illustrated that progress will reach its maximum potential if we collaborate as a multiprofessional team in the planning department.
Thor Stenbeck was a hero, but a century later we should not emulate him and his dual roles.
Dr Richard Simcock has been a Consultant Clinical Oncologist at the Sussex Cancer Centre since 2004. Previously he had worked at the Sydney Cancer Centre, Australia and before that had completed five years of postgraduate specialist training in Oncology in London and the South East including Guys and St.Thomas’, Charing Cross and Mount Vernon Hospitals. He graduated from Guys and St.Thomas’ hospital in 1993.
Working closely with the surgical and nursing team Dr Simcock sees and treats patients diagnosed with early or advanced breast cancer. He advises on the role of radiation, chemotherapy, hormone, biological, and experimental treatments.
Dr Simcock prescribes and supervises courses of chemotherapy delivered by the team at the Montefiore or by home healthcare teams. In addition he prescribes, plans, and supervises radiotherapy treatment at the Royal Sussex County Hospital or at Spire Portsmouth (CPUK).
He is also involved in enrolling patients in trials of new therapies as well as trials of improved radiation therapies.
As a Head and Neck Oncologist Dr Simcock treats cancers of the larynx (voice box), tongue, tonsil and other rarer sites. He supervises, prescribes and plans curative treatments with radiotherapy and chemotherapy as well as giving post-operative radiotherapy treatments. Intensity Modulated radiotherapy is used as standard in these cases.
Charlie McCaffrey, from Carestream Health reviews the world of medical imaging in 2013 and takes a peek of what lies ahead in the new year.
The dawning of a new year provides an opportunity to look back and reflect on the previous year. Surveying the diagnostic and therapeutic imaging landscape in the UK, 2013 was an interesting year. The publication of the Francis Report in February was a pivotal moment that will have long lasting consequences for the NHS. February also saw the official opening of the BIR’s new premises in St John Street and I was privileged to be in attendance at the opening ceremony and attend my last Council meeting as a Trustee there in September.
Liverpool hosted the UKRC in June for the first time and the event was a huge success.
In August, the government announced a commitment to establish two proton beam therapy centres by 2018: an exiting development for UK cancer treatment and the imaging community as a whole. August also saw the publishing by the DoH of “Better Procurement, Better Value, Better Care: A Procurement Development Programme for the NHS” which aims to build a modern, effective and efficient procurement capability in the NHS that is among the best in the world.
On the business front, we saw unprecedented activity in the RIS, PACS and Vendor Neutral Archiving space, with what can be described as a tsunami of implementation activity in the first half of the year as many NHS Trusts in the southern cluster and the North West and West Midlands cluster of the Connecting for Health Programme opted to exit the Programme and procure, implement and manage their own IT solutions.
Despite the establishment of the DoH Capital Equipment Fund, purchases of high-end imaging modalities by the NHS continued to be depressed with CT scanners, MRI units and general X-Ray room all failing to recover, a point highlighted elsewhere by my fellow industry bloggers. This will continue to be a challenge for the NHS with an ageing installed base and is a source of frustration given the significant savings being generated through the closing of the Connecting for Health Programme. It is imperative that these savings are channeled into investment in innovation to enable patients and staff to benefit from the faster throughput, lower patient exposure and lower total cost of ownership offered by new imaging modalities.
Looking forward to 2014, the NHS will continue to be a challenging environment in which to work and operate. The move to 7-day working will continue to accelerate against a continually challenging economic environment. More NHS Trusts are expected to exit the Connecting for Health Programme. On the technology front, imaging modalities will become more compact, efficient and faster, have higher throughput and lower dose and be more flexible. Healthcare IT solutions will become more portable, feature-rich and integrated. And on the political front there is the not insignificant matter of the Scottish referendum on independence in September, something, as a native Glaswegian, I will watch with much interest!
In closing, I would like to take this opportunity to wish the BIR continued success for the future and wish you a Happy New Year.
Charles McCaffrey, Cluster Manager – North Europe and Managing Director UK & Ireland, Carestream Health.
(Charlie is also Chair of AXrEM—the Trade Association of Healthcare Technology Providers for Imaging, Radiotherapy and Care)
Karl Blight, UK and Ireland General Manager at GE Healthcare considers how imaging technology can help tackle the funding challenge facing healthcare
NHS England’s recent strategy paper, ‘A Call to Action’ Identified a potential £30 billion funding gap between spending and resources by 2020-21 if services continue to be delivered as they are now. This challenge will require significant changes in how healthcare is provided so that productivity can be improved and costs reduced.
While much attention will be paid to structural changes around how the NHS is organised, and to where and how patients access healthcare and are treated, funding decision makers need to recognise that investment in appropriate technology can make a major contribution to improving the efficiency of the healthcare system. There is a general misconception that the up-front cost of healthcare technology is prohibitive and, at a time of economic austerity, should be amongst the first areas to be constrained. But, this can be a false economy. Persisting with older technology can lead to higher maintenance costs, disrupted patient appointments due to increased downtime and slower scans, while newer equipment can increase productivity with higher uptimes and better quality images that enable more confident diagnoses and make repeat scans less likely.
Meanwhile, some newer scanners feature state-of-the-art technology that can help save time for clinicians and reduce the burden of paperwork, for example connecting to field engineers who help solve issues remotely so that clinicians can focus on providing patient care. In addition, many medical device manufacturers are investing in the development of new products which have been engineered to meet specific needs at a lower price point. Many are specifically designed to be portable and efficient to operate for the user. Not all situations require the high end technology, and manufacturers are providing equipment that can be tailored to the particular needs of the user or service.
Revolutionary developments in medical technology encompass not only the physical kit. The rise of digitisation, particularly in imaging and in data analysis, transfer and management, is good for the patient and also has huge potential to boost productivity. The combination of big data analytics and clinical information is helping healthcare professionals to identify issues, design solutions and implement patient and system level changes much faster than previously possible. There is a vast reserve of data in healthcare and we are only at the beginning of making the most of it.
The medical device industry, by investing in the development of new technologies, is playing an important role in helping practitioners to deliver better, more cost effective care to patients. Clinicians and technology providers alike now need to ensure that UK healthcare budget holders don’t just focus on the perceived costs associated with new equipment, and instead understand and recognise the value, productivity potential and long term benefits that investing in appropriate technology can bring, both to improving patient care, and to helping the NHS meet its funding gap.