Going Digital

The introduction of digital technology has revolutionized the way in which imaging is being used, and as Chairman of the Board of the largest organization of radiologists in the world, the Radiologic Society of North America, no one is better qualified to make such a judgment than Burton Drayer.

“We have the potential to find the disease not four years after it's pretty obvious to anyone who speaks to the patient, but four years before they develop symptoms”
-Burton Drayer, The Radiologic Society of North America

With the introduction of digital imaging, the use of film has been eliminated, and all images are now examined using computer screens on a workstation, which provides tremendous advantages. “The main advantage is that film can only be in one place at one time. If you’re at a large hospital or if you have multiple referring physicians, there’s only one set of film so they all have to borrow those films and bring them back to a certain place. This can lead to films getting lost, and many other difficulties,” says Drayer, who is also Chair of Radiology at Mount Sinai Medical Center.

The accessibility of digital images by numerous physicians across numerous locations means the technology can only benefit the patient. If the patient is seen in London and then referred to a hospital in New York, their movements are followed by the digital images via technology, so the patient no longer needs to transport the image with them overseas. Instead there is immediate transmission of the images to the physician.

For Drayer, this is a drastic improvement: “Within minutes after a study is done we can have the results. The images provide results that are accessible to all individuals: those who have to interpret them and those who have to treat based on those interpretations. All of this is available immediately. In addition, all of our modalities – CT, MRI, PET scanning – all have digital outputs so it is a very efficient way of just running day-to-day operations over a radiology department.

“It’s a move away from the requirement to have a darkroom when using film, and there is also no longer the need for chemicals that were used during the processing of the film.”

Double-edged sword
However, it is its own advancement as a technology that is responsible for certain challenges in using digital imaging. Drayer notes that although digital imaging is perceived to be straightforward, that is not always the case. With each institution at a different stage of implementation of a digital system, and with a wide variety of systems between hospitals, the transfer of the images is not always flawless.

“The challenges come when there are firewalls at different institutions. Everyone is not on the same system. This is a huge focus for the Radiologic Society of North America, which sponsors a very large project called Integrating the Healthcare Enterprise (IHE), and what that does is provide connectivity. It supports connectivity between different types of machines, different types of software, different types of modalities, different types of information, and tries to give us a common pathway, allowing everyone to share information.”

Generally, the transfer of images within the same institution is seamless, as the same system is likely to be used throughout. “The problems simply require cooperation from the vendors who are making the equipment and from the physicians who are interpreting the images. There are obviously patient privacy issues that are incredibly important as you begin transferring images. We have the privacy provisions of HIPAA –the Health Information Portability and Accountability Act – where we have to look at patient privacy, which is incredibly important to us. So we have to deal with those additional issues when transferring images,” says Drayer.

Drayer’s team is using the technological advancements to further research into early detection of Alzheimer’s, Parkinson’s and brain functions. “We’re looking at modalities very similar to what are looked at all over the world right now. Magnetic Resonance Imaging (MRI) continues to be extremely important in both Alzheimer’s and Parkinson’s and is probably of greatest importance in diagnosis, as it provides significant information to exclude other diseases that might mimic Alzheimer’s or Parkinson’s.

“For example, if someone has a brain tumor or a stroke and it appears to the clinician as though it’s Alzheimer’s or Parkinson’s, but really it’s not – it’s a brain tumor, stroke, subdural hematoma or some other type of disorder. It’s hugely important to ensure that it’s not something that may be treatable by a different means. Then you use some of the fancier tools that we have with MRI to determine if it cannot be diagnosed to any of those, to confirm if it is Alzheimer’s or Parkinson’s. For this we use profusion imaging. We use what we call diffusion tensor imaging and functional MRI. Through the use of different types of techniques, we can better understand not just the anatomy or the structure of the brain but also its function.

“Another thing we use a lot of is positron emission tomography (PET), which we use with fluorodeoxyglucose for Alzheimer’s disease. There are new agents for Alzheimer’s disease that are now being used that bind to amyloid which are very exciting that may be more specific for Alzheimer’s disease using PET,” he explains.

Prevention
At least one third of the US population is predicted to be over the age of 55 by the year 2030, leading to a substantial increase in the number of patients needing treatment for Alzheimer’s and Parkinson’s. “Our goal is to detect the disease early before it becomes symptomatic, and then hopefully be able to treat it and prevent it from actually occurring. That’s why imaging is so exciting. We have the potential to find the disease not four years after it’s pretty obvious to anyone who speaks to the patient, but four years before they develop symptoms.

“That’s where the excitement occurs, which is what healthcare should be in many ways. It’s prevention. It’s looking at how we can detect a disease through imaging – whether it’s through your genetic makeup, your anatomic makeup, your functional makeup or your metabolic makeup – just as you might use a cholesterol or lipid to look at cardiac diseases, and conduct preventive measures,” says Drayer.

Excitement is the operative word for Drayer and his team, given the recent election of the new administration in Washington and its focus on healthcare reform. However, Drayer notes the limitations of placing increasing importance on IT in the current economic climate. “One thing the new President underestimates is the cost of information technology. When you’re using computer-based systems, it’s expensive. It’s terrific. It’s fantastic for patient care but has its costs and these costs are recurring. You have to upgrade the equipment all the time.

“On top of all this, you have all these contrast media and new imaging agents being developed that are attempting to make us more specific in order to potentially detect disease at an earlier stage or detect the type of disease that might be more dangerous. For instance, because a blood vessel has atherosclerosis in it doesn’t mean that you’re at risk for a heart attack or a stroke. The question is which of those plaques that we see are vulnerable. When we start to make those determinations, that’s where imaging can play a tremendous role.”

Research
Drayer’s research team is primarily focused on highlighting the model of prevention through the development of detection, and its work with the new Translational Molecular Imaging Institute is an expansion of their research activities. Drayer notes that the current buzzword within imaging is molecular. Molecular imaging is looking at not just the structure of a disease or the normal individual, but also the function and the metabolism through the use of imaging. This not only detects disease but also follows the progression of treatment, and determines if the treatment is successful. This is of the highest importance to the Institute and is one of the three-pronged approaches that it is using to conduct research.

“The second area that is always important with imaging is physics and engineering, and as we develop these fantastic machines – MRIs, PET and CT scanners – that are faster and better and show us smaller structures, this takes tremendously advanced physics engineering.

“Then the third direction we’re taking is image management. One of the advantages of using information technology and PACS, from which we read images from on workstations, is being provided with a tremendous amount of information, which keeps doubling and quadrupling every year. However, we need better systems to manage all of this information and process it in a form that we can use in a more efficient fashion.

Training
In order to ensure research is carried out in the most efficient and beneficial way, the radiology faculty concentrates heavily on high level, informative training of its next generation of diagnostic and interventional radiologists. Drayer explains that the traditional teaching method is to use one-on-one teaching while interpreting images, along with research and clinical conferences.

“We also try to use all of the available online materials. More and more the RSNA, along with other societies, is trying to provide as much online material as possible, and one of the exciting things is now you can look at some of this online material while you’re reading your images. While you’re doing your interpretation it’s like having a textbook in front of you to read about all the other nuances that might be available, which has been a very good teaching tool,” he explains.

As radiology changes in its function, so do the methods of research and the training tools. Radiology is no longer simply a process of diagnosis, there’s now a tremendous amount of therapeutic treatment with interventional radiology, which has led to more and more minimally invasive techniques to treat many diseases.

As a preventative model becomes endorsed across our healthcare system, radiology is expected not only to meet these new methods, but to also become active in the therapy of diseases too. Only time will tell if Drayer’s team is able to meet such demands, but with a wealth of knowledge and a multitude of experience, the odds are definitely in its favor.

Burton Drayer is Chair of Radiology at Mount Sinai Medical Center in New York City and Chairman of the Board of the Radiologic Society of North America.

Imaging definitions

MRI
Magnetic resonance imaging (MRI) is a non-invasive procedure that uses powerful magnets and radio waves to construct pictures of the body. Unlike conventional radiography and computed tomographic (CT) imaging, which make use of radiation (X-rays), MRI imaging is based on the magnetic properties of atoms.

A powerful magnet generates a magnetic field roughly 10,000 times stronger than the natural background magnetism from the earth. A very small percentage of hydrogen atoms within a human body will align with this field. When focused radio wave pulses are broadcast towards the aligned hydrogen atoms in tissues of interest, they will return a signal. The subtle differences in that signal from various body tissues enables MRI to differentiate organs, and potentially contrast benign and malignant tissue.

PET
Positron emission tomography, also called PET imaging or a PET scan, is a type of nuclear medicine imaging.

Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose or treat a variety of diseases, including many types of cancers, heart disease and certain other abnormalities within the body.

A PET scan is a diagnostic examination that involves the development of biologic images based on the detection of subatomic particles. These particles are emitted from a radioactive substance given to the patient. The subsequent views of the human body are used to evaluate function.