Medical imaging is part of a changing medical environment, a changing patient environment and consequently a new medical world. In the recent decennium one of the most important changes in radiology is the conversion from analogue to digital. In no time medical images have become interchangeable through the digital highway and could be postprocessed in a different location. Teleradiology has become a reality since then. We have seen the maturation of commercial international teleradiology companies offering a wide portfolio of services. Another aspect is the availability of image data for all medical specialties beyond radiology and beyond the regular medical disciplines. An increasing number of surgical or oncological specialties and even pharmaceutical companies increasingly use image data to prepare a strategy for operative procedures, to choose the right therapy, to decide which prosthesis to the best to use, for follow-up or for post-processing purposes. They are supported by many new techniques and software. An increasing number of medical computer applications such as complex navigation and visualisation tools based upon digital images is already in clinical use or under development. Another trend is the increasing interest in E-health and telemedicine in Europe, also among European policy makers. Now we see mobile health that brings care directly into the patient environment. The purpose of this presentation is to give a comprehensive overview of and insight into these new developments and to create awareness among radiologists of the increasing importance of integration of medical imaging in a multidisciplinary environment.

1. Image data beyondradiology: newdevelopments Dr. E. R. Ranschaert1Dr. F.H. Barneveld Binkhuysen2 Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, NL Independent Hospital & Healthcare Professional, Soest, NL

2. Introduction Radiology is a heavily IT-driven specialty, and therefore prone to many new developments Other significant factors that influence this process: technical developments & scientific progress political & economical changes New developments in relation to radiology concerning treatment (surgery and oncology) imaging techniques PACS e-Health Discussion of effects of these developments on radiology and patient care

4. teaching hospital

5. 240 medical specialists

6. 4000 employees

7. 500.000 consultations/year

8. 250.000 radiol.ex./year

9. 88 medical residents

10. EPR and digital image archive

12. Endoscopic Surgery Suite Hospital network Communication via hospital network Central storage Consulting patient file from PACS II Olympus Endoalpha Control Unit

13. Images beyondradiology: surgery Integration of images in surgical procedures for strategic planning procedure guidance patient-specific treatment (custom-made implants) teaching (live) International trend: new surgical societies ISCASInternational Society for Computer Aided Surgery ISMICSInternational Society for Minimally Invasive Cardiothoracic Surgery CAOS-international Society for Computer Assisted Orthopaedic and Spinal Surgery

14. Example: from image to implant Perfect fit ! Image with courtesy of Siemens Healthcare

15. Images beyondradiology: oncology Integration of imaging in planning & monitoring cancer treatments functional imaging: CT/MRI diffusion and perfusion, PET-CT, PET-MRI (Automated )quantitative imaging methods (staging , F.U., early response) Integration of interventional radiology & surgery TACE, RFA, radio-embolisation, cryo-ablation, micro-wave ablation...followed by surgery (e.g. liver) preoperative strategy planning with automated 3D segmentation e.g. liver, breast – new developments arFraunhofer MEVIS Integration with radiotherapy: IGRT with dynamic targeting CT and even MRI Integration with chemotherapy MRI-guided chemo (temperature-induced drug release)

17. effectiveness is currently limited due to variability in:

18. imaging hardware

19. post-processing software

20. calibration

21. lack of standard protocols

22. ongoing research to improve automated image-based assessment and comparisonSource: website Laboratory of Imaging Informatics, Stanford University

23. Quantitative imaging & CAD Automated tumour staging and evaluation Automated detection: CAD systems Images with courtesy of Siemens Healthcare

24. Quantitative imaging Integration of morphological and functional information

25. Images in oncology: treatment IGRT TACE Mark tumor-feeding vessels Automatic calculation centerline Overlay on live fluoroscopy

29. 4D: advanced dynamic imaging Images courtesy of Ziosoft

30. 4D: advanced dynamic imaging Images courtesy of Ziosoft

31. 5D: dynamic + functional Images courtesy of Ziosoft

32. 5D: MRI + functional PET/MRI images, with courtesy of Siemens Healthcare

33. Developments in PACS (PACS II) Improved interoperability with other clinical IT-systems, HIS and EPR using IHE standards Embedding of clinical tools on 1 single workstation such as: documentation sharing (XDS/XMS), VoIP, integrated voice recognition Easy access anywhere/anytime (web-based thin client, mobile) Further integration of : pathology images (interactive display of the microscopic fields), endoscopic images (video sequences, video capsule) dermatological images surgical imaging: development of “surgical PACS” based upon DICOM and IHE, integration of therapy imaging and model-guided therapy (TIMMS)

34. Seamless integration and interconnectivity The biggest gains will come from the seamless connectionof RIS/PACS and EPR with images Integration of other applications should appear seamless to the radiologist The longer term solution is to make transmural image transfer by DVDs and CDs unnecessary. This requires an interconnected, broadly based EPR system (“virtual cloud”)

35. Future PACS The future PACS will be a "portal" to radiological knowledge: integration of web-based access to scientific literature and information pertaining to diseases incorporation of quantitative imaging methods automatic retrieval of images similar images to those under review, to help with making diagnoses Source: Laboratory of Imaging Informatics, Stanford University http://www.stanford.edu/~rubin/projects.html

36. PACS-Web Integration The (anonymised) data contained in a future connected web of EPR’s could be mined for medical knowledge This knowledge could then be put into a national or pan-European databasefor use in making diagnoses and choosing therapies Ability to capture this information in a usable form depends on technology physicians' willingness to use software-rendered advise privacy regulations, financial & political support

37. Developments in e-Health Many new developments in radiology are now driven by the consumer Changes that have increased the appetite for health information : wide-scale access to the Internet inexpensive PC’s mobile devices and services merged functions of cell phone and PC Patients are empowered to research medical questions and have the means to own the results of imaging exams and lab tests Simultaneously political initiatives are taken to make healthcare more efficient through the widespread use of IT Changes are often driven by cost-saving motives and intentions to allow patients to have better control of own health

38. e-health and m-Health EC eHealth action plan 2007 iPhone 2010 M-Health revolution 1 billion use Internet 3,9 billion cell phones Dot com Bubble bursts HIPAA 2008-2012 Wiki Health Google Health 2007-2008 Health 2.0 conference Disease- specific online communities 2002-2006 Patient Support Groups develop 1999-2000 WWW access to Health info 2004 Ireland EU conference Empowering patients

39. e-Health is on political agenda e-Health congress, feb. 2011, KNMG EC vice president NeelieKroes stated that healthcare can be improved with e-Health “We need to be more aware of the fact that ICT needs to be integrated in our HC system. Almost every MD has a smartphone, so much more can be done with that”

40. m-Health for patients Patients want same accessibility to their health information as with “banking” Examples of existing services: Web-based bookings SMS appointment reminders: radiology, laboratory, … In the next 2 years patients will expect access to lab data and radiology reports—and even images and other types of health information—online

41. m-Health for professionals Professionals are increasingly making use of mobile appliances and applications for mobile devices FDA approved image reading software for iPadis already available Soon mobile devices will not only display images but capture, gather, and aggregate information so well that hardly any interaction with RIS and PACS is needed

42. e-Radiology or i-Radiology? Mobile MIM viewer remote diagnostic imaging tool for iPhone/iPad 14 languages FDA-approved jan. 2010 Meets Medical Device Directive 93/42/EEC Cloud computing technique is used to create “virtual PACS”

45. The changing environment: summary New developments in patient treatment (oncology, surgery...) Minimal invasive surgery and intervention techniques Cancer-specific treatments guided by imaging New developments in imaging From 2D  5D New developments in PACS PACS II: availability of image data from/for other specialities better integration of RIS/PACS with EPR and other apps Increasing consumer-driven developments in e-Health Consumer access, “patient empowerment” “mobile health” e-radiology or i-radiology

46. Effect on patient care Diagnosis and treatment are becoming better and less invasive: higher quality of care, more patient comfort, increased safety Patient-centred medicine with a more individualised approach Increased cost-effectiveness of healthcare: timely discontinuation expensive medication (oncology) less redundancy of high-volume exams (transmural access) But… no evidence yet for cost-effectiveness of e-Health until now! * Patient “empowerment” with new clinical/radiological services Personal digital Health Record & image archive Development of more patient-oriented services Increased accessibility of expert advise (*) Black AD, et al. 2011 The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. PLoS Med 8(1): e1000387. doi:10.1371/journal.pmed.1000387

47. Impact on radiology These trends and developments promise to fundamentally change radiology Widespread availability of patient data will change the way radiologists and interact with each other, referring doctors and patients Referring physicians will be able to use mobile devices to get instant information about their patients Patients will be able to build & manage their own HR and image archive Radiologists will benefit if they make an effort to adapt to these changes Trends in imaging IT forecast changes to radiology practice Diagnostic Imaging, Greg Freiherr, 5 March 2010

48. Impact on radiological workflow Change in reporting strategy: Incorporate more information (PACS II + EPR) Analysis of dynamic, functional and clinical information Analysis of greater image archive (transmural) Make reports more “comprehensible” for patients New competences and subspecialty training needed Gatekeeper role for radiologist needed Danger: possibly overflow of information Solutions & tools to handle all this information effectively?

50. Re-arrangement of tasks (PA, trained radiographers)

51. Make use of e-Radiology, balancing of workload

52. cross-institution sharing of work lists

53. transmural collaboration (expertise centres & tertiary centres)

54. partial outsourcing of expertise

55. Invest in decision support tools

56. to help reducing the number of redundant examinations

58. Diagnostic Decision Support artificial intelligence software created to search & analyse images in PACS searches based upon image features including : feature descriptors (RadLex) computer-generated features of pixels characterising the lesion Source: Laboratory of Imaging Informatics, Stanford University http://www.stanford.edu/~rubin/projects.html RadLex: http://radlex.org

60. image data should be made available in a standardized, anonymous form

63. Efforts are made to create the equivalent of the world wide web to exchange medical information

64. Grid Computing may be the answerhttps://bmir.stanford.edu/pages/view.php/biomedical_imaging_isis

65. Conclusion There is a risk that radiologists will only be passive acceptors of these changes, rather than being active in planning for changes and steering their implementation These new developments are an ongoing process which we need to be aware of We need to reflect about our future role and adapt our workflow to these changes We need to think broad & creatively to provide added value More investments need to be made in e-Health apps Structural financing is needed and needs to be found

66. Thank you! e.ranschaert@jbz.nl