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5 Things to Watch in 2008 —
Hot Topics From RSNA What’s the buzz at RSNA 2007? And what will have the greatest impact on the future of radiology? Those questions always come to mind as I sit in sessions and walk through the massive exhibit halls. This article outlines five observations from this year’s meeting that I think will prove important in 2008 (and beyond) to radiologists, administrators, technologists, and the facilities where they work. 1. Teleradiology and the role of radiologists. What will the radiology practice of the next 30 years look like? That answer is a guess, but it won’t look like the practice of the past 30 years. “There’s no doubt about it—the world of medical technology is changing at an ever-increasing pace and there’s no stopping it,” RSNA President R. Gilbert Jost, MD, said in his Presidential Address at the meeting. “But this is no time for complacency. We have many challenges, but we have many advantages. We need to be prepared to give up many of the ways of the past in order to be prepared for the more complicated world of the future.” The principal way of the past that radiologists must give up: the notion that they control the images because they control the “film.” “PACS allows information to come to me,” Paul J. Chang, MD, said in the opening session. “Unfortunately, the information can also go to anyone else while I’m sitting in a dark reading room looking at images and marginalizing. That is the road to commoditization.” How far down the dreaded commoditization highway radiology has already traveled—and whether there is any place to exit—depends on who you ask. Some see technology and teleradiology as an important part of stretching radiology supply to meet a larger demand. Others see it as the beginning of commoditizing radiology interpretation and increasing competition among radiologists, which once was only feasible on a local level. “Local radiologists might view themselves as an integral part of a healthcare sequence; however, we have to be aware of another opinion,” radiologist James Borgstede, MD, warned attendees at RSNA’s opening session, “and that is that others may view radiologists as middlemen, creating an obstruction to healthcare delivery rather than facilitating it. And whether we agree with that opinion or not, that opinion is out there. “So let me portray a scenario that is going on out there now. And that is hospitals out there looking for new sources of revenue and teaming with after-hours teleservices. And they can eliminate up to a third of previously independent billing radiologist positions simply as a middleman. How would this work? Hospitals where radiologists’ incomes are significantly higher than an after-hours service—and I would estimate that to be a quarter or [one] third of all positions—are at risk. The hospital terminates the radiologists and contracts with an after-hours teleservice for a fixed, off-the-top profit. The teleradiology service then bills globally and becomes a daytime service. And the hospital and the after-hours service split the profits of what I would estimate to be $100,000 or more per radiologist by simply paying average radiologist salaries for what were higher-than-average positions…” But in general, radiologists are in tight supply, and it’s difficult to argue against teleradiology firms’ capability to redirect work to places where radiologists are available to do it. For example, if a radiology group has been recruiting for three years to find a pediatric subspecialist, it’s hard to blame them for contracting with a teleradiology group to provide that service. Estimates tossed around at RSNA suggest that 80% of all radiology groups utilize teleradiology services in some form—from night and weekend call coverage and subspecialty reads to overflow work and final reads. If that percentage is accurate, it certainly suggests that demand exists, even if it is predominantly a tool radiologists use to avoid a night and weekend call. As long as demand clearly exceeds supply, Borgstede’s dire scenario for radiologists probably won’t become widespread. There’s plenty of growth potential for teleradiology companies to pursue without competing against the radiology groups that are their customers. Executives from both NightHawk Radiology Services, LLC, and Virtual Radiologic Corporation reiterated that point in separate interviews at RSNA . When supply more closely matches demand, that could change. Teleradiology seems poised to be part of the typical radiology practice—if the 80% figure is close to accurate, it is already part of most. Expect successful practices to be a mix of on-site radiologists augmented by the teleradiology services necessary to provide complete radiologic care to the facilities they service. “Radiologists must develop a long-term rather than a short-term perspective for the problem of commoditization,” Borgstede said. “The short-term perspective is to find somebody to take call so I can sleep tonight. A long-term perspective is to have a secure practice so I can sleep at night for the next 20 years.” 2. Networking information. A PACS vendor told me his firm entered the RIS business because customers expected an integrated RIS/PACS product. He said it didn’t matter that their PACS already integrated smoothly with any RIS because customers now expect an integrated RIS/PACS. That little story illustrates the steadily spreading understanding that more tightly integrated and interoperable information systems represent a real opportunity to increase efficiency, improve patient care, and save money. From computerized contrast injectors linked to RIS and electronic medical records to automated volumetric ultrasound that can be stored digitally, the mindset is changing to one that understands all radiology information needs to be digitized and centrally stored so it is available to whoever needs it wherever they have computer access. “Radiology needs to continue to strive to lead the pack with respect to bioinformatics,” Borgstede said. “For specialties that understand and harness the power of information technology are likely to avoid being swallowed up by the pace of technologic change, which is inevitable.” 3. Rethinking CT slices. As the number of detectors on multislice CT systems spiral higher, there is evidence that manufacturers are thinking CT images are about more than just increasing the number of slices. Toshiba jumped ahead in the slice race with the surprise unveiling of its 320-slice scanner. Interestingly, the company chose to take the focus off slices by calling the experimental system Aquilion One. It’s focus was on the new system’s 16-centimeter coverage area, which enables the Aquilion One to scan most organs in a single pass, reducing scan time and dose. Philips Medical Systems rolled out its 256-slice Brilliance iCT. With its gantry rotation speed of four rotations per second, it can scan an entire heart in two heartbeats, and the company claims it can reduce radiation dose by as much as 80%. Siemens Medical Solutions introduced its Somatom Definition AS line, which can be configured in 40-, 64- and 128-slice configurations to match a facility’s need. Siemens also offers its Definition Dual Source CT with two 64-slice detectors on one system. Siemens touted updated gantry and detector designs to increase imaging speed and reduce dose. GE Healthcare displayed plans for a new garnet-based detector that it’s calling high-definition CT and plans to implement for its LightSpeed VCT line. The idea is that better images per slice are at least as important as adding slices. 4. Reimbursement reduction and cost cutting. The Deficit Reduction Act of 2005 reimbursement cuts kicked in this year and imaging facilities—especially freestanding centers and physicians’ offices—are feeling the pinch. Few people in attendance at RSNA felt that the reimbursement pressures squeezing radiology are going to relent anytime soon. Facilities are looking for ways to increase efficiency and reduce costs, as well as increase imaging volume; they’re pressuring vendors to develop and refine products to help them do that. 5. Reducing radiation dose. Limiting patients’ exposure to ionizing radiation has long been a concern. The topic received an extra boost during RSNA 2007. One study presented at the meeting pointed out that pregnant women had been, on average, exposed more than double the radiation in the past 10 years than in previous the previous decade. Also during the show, USA Today reported on a study published in The New England Journal of Medicine noting that approximately one third of the 62 million CT scans performed in the United States are medically unnecessary. “On average, we now get double the radiation exposure we got in 1980 because of increased CT scans,” study author David J. Brenner, PhD, DSc, told USA Today. “Virtually anyone who presents in the emergency room with pain in the belly or a chronic headache will automatically get a CT scan. Is that justified?” The newspaper article really didn’t mention potential reasons for the increased exposure, such as defensive medicine and self-referral. The newspaper article also mentioned new scanners from Toshiba and Philips that reduce radiation exposure by up to 80%. Given that a high percentage of RSNA 2007 attendees received the paper at the door of their Chicago hotel rooms, it’s hardly surprising that discussion was common at the meeting. It also makes sense that in a world where more CT scans are performed each year, focusing on the radiation exposure and how to minimize it are real concerns. — Jim Knaub is editor of Radiology
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