During morning rounds, a physician visits with every patient, not once coming upon an empty room. A radiologist on the West Coast interacts on a study with a colleague on the East Coast?in real time. In a major metropolitan emergency department (ED), the trauma team organizes appropriate treatment for a patient?before the ambulance even arrives at the hospital.
An episode of The Twilight Zone? Hardly. In fact, before long, scenes like this will be taking place across the country. Driven by a new breed of wireless technology and the creative minds pushing it to its limits, the future holds great things for physicians and patients alike.
In a perfectly wireless world, information would not be limited by distance. Using a personal digital assistant (PDA), paramedics record a critical patient’s vital signs as they load the patient into an ambulance equipped with a live, bidirectional video link to the hospital.
While the patient is en route to the ED, the trauma team at the facility could prepare as necessary. If surgery or radiology is required, available rooms would be noted, and appropriate staff members would be alerted automatically. As the vehicle backs up to the ED, the data would transfer to the hospital’s wireless system, transferring all information into the patient’s file.
Once in the care of hospital staff, the patient would be outfitted with a wristband that not only monitors his or her location, but also alerts clinicians of possible drug interactions.
Individuals like Evan Bontemps, president and CEO of Pannevera Inc (Newmarket, NH), are helping bring this dream closer to reality.
“We are developing long-range RFID Web-based appliances,” he says. “This provides the ability to automatically locate any asset within the hospital, be it the patient or mobile electronics.”
Radio frequency identification (RFID) technology makes it possible for the capture and transfer of data between a reader (or readers) and multiple tags through induction. Because communication between the reader and a tag is automatic, it provides a highly efficient way to track objects?or people?by simply adorning them with an RFID device.
Because all data is stored on the network, not on the tag, the systems are more affordable than in previous years. Also, benefits go beyond just identifying the physical location of a specific piece of equipment. For instance, RFID asset tags can indicate if the equipment is operational and if it is due for servicing.
“Based on the data accessed via the tag attached to the device, [staff members] also could know exactly what the machine is capable of doing,” Bontemps says. “For example, it would indicate whether a pump is specifically for blood transfusions or for saline solutions.”
The solution is currently undergoing clinical trials, and Bontemps expects that it will be available commercially in September.
A Brave New World
If employee identification (ID) badges bear RFID tags, the network could monitor their locations and interactions with patients and equipment. The network would continuously gather information from all tags?comparing data and sounding alarms when programmed. One example is equipment, such as portable ultrasound devices, nearing an exit unaccompanied by an employee badge. Exactly what would happen in such a case depends on the preferences of the facility’s tech team, but possible responses could range from alerting security to the automatic locking of all doors and elevators.
Maintaining all data on the network makes the tags less expensive and makes the data they fetch more secure. It also provides a way to monitor patient information more closely than ever before. Ideally, a nurse would enter the patient’s room with a wireless device, such as a PDA or tablet PC. As he or she approaches the patient, the network reconciles the information from the nurse’s ID badge, notes his or her privileges for the patient, and all associated records would load automatically to his or her wireless device.
Ease of scheduling would improve as radiology-department heads effortlessly track exactly when and how often their imaging systems are put to work.
And last, but certainly not least, physicians also would realize benefits as they make rounds. A radiologist, for example, would know not only when the patient’s exam has been completed, but also whether the patient was actually back in his or her room.
Physicians also would be able to receive study images anywhere in the hospital.
“The beauty of this is that the radiologist can start formulating thoughts on how he or she can begin to treat the patient immediately,” Bontemps says. “As opposed to waiting for images, the information will be available on his or her tablet PC, wherever the radiologist is.”
Bontemps envisions a time when paper files are a thing of the past. “Once they’re using mobile devices, nurses will be able to move from patient to patient?connecting wirelessly into the network simply by entering each room,” he says. “This means they have more time to spend with patients, improving customer service and employee job satisfaction.”
For individuals who find going completely paperless more worrisome than comforting, the network is designed with redundancies that guarantee the ability to access data?as long as there’s electricity, including a backup system available in the event of power failure.
“Our solutions are deemed to be fault-resilient. We ensure the integrity of the data, and we also ensure that there is always a path to the data,” Bontemps explains. “But the facility is responsible for having an uninterruptible power supply to provide power to the servers. We do not control that, but we can help them design the network to become fault tolerant.” (For more information on power supplies and issues, don’t miss this month’s “Absolute Power” article.)
RFID makes it possible to closely monitor components of a building, but a system being created at the University of Chicago makes it possible for physicians to interact regardless of how far they are from each other. The Advanced Biomedical Collaboration (ABC) test bed is a technical framework based on the Access Grid, an infrastructure that allows multiple streams of data to travel between multiple locations simultaneously.
“Unlike traditional teleconferencing, it’s not point to point; it’s very different in that you can have multiple simultaneous streams,” explains Jonathan Silverstein, MD, MS, FACS, assistant professor of surgery in the Section of General Surgery at the University of Chicago, director of the University’s Center for Clinical Information, and senior fellow of the University’s Computation Institute. “[The goal is to] move us beyond telemedicine to telecollaboration, with medical professionals at each of the multiple ends of the system, each giving interpretive information.”
The technology holds particular promise for the imaging community, because the data that can be shared?including physiologic information, radiological data, and video?is far more complicated than basic telemetry.
Coming Stateside Soon
At RSNA 2005, Agfa Corp (Ridgefield Park, NJ) demonstrated its new adaptive streaming technology in the booth’s “Emerging Technologies” area. This Web-based image-distribution application makes it possible for physicians to access images and reports on any wireless device, without being limited by bandwidth. Regardless of when, where, or how, radiologists have access to full clinical functionality and data, including 3-D image data.
Radiologists are able to collaborate remotely with colleagues and referring physicians?all in real time. User-friendly screens navigate the proprietary and patented predicted streaming technology that transmits images, reports, and patient information to physicians without transferring data from the archive. The product is expected to be available for inclusion on all US IMPAX systems later this year.
“We’ve demonstrated that you can use the system to transmit stereo-video signals, meaning the video itself is running in 3-D,” Silverstein says, adding that the system is still a prototype. “We will be able to plug directly into surgical devices that send laparoscopic stereo-video signals and transmit over long distances in multiple locations, allowing a group of people to see?in 3-D?the anatomy being operated on.”
To help minimize the draw on available bandwidth, the ABC test bed will feature a type of visualization system that allows users to send video streams in pieces rather than as one large file.
“You’ll be instantly loading it in one place and opening a channel to somewhere else,” Silverstein says. “You don’t have to send the entire DICOM data set, just the information you’re visualizing.”
Though much of the work is still in development, some University of Chicago anatomy students will benefit. As part of a pilot program, students will look inside the human body?without actually seeing one.
Through the “Virtual Anatomy” course offered in the spring semester, University of Chicago students will have a “cadaver” in the form of high-resolution CT scans.
“By changing the dynamic range of the data and using three-dimensional cutting planes, we explore and find the interesting anatomy the way you would with a cadaver,” Silverstein says, adding that a color algorithm created by his team automatically applies colors based on tissue type. Because all of the course data is housed on the Access Grid, students can log on to access their “body” from any location, at any time. “Students can use the same tools on their desktop, and it can be three-dimensional,” he says. “In a sense, the textbook can really come alive.”
There’s no denying that automation and technology improvements have brought a host of benefits to radiology, but the transition to a filmless, PACS-powered world has not been flawless.
“We are a completely filmless hospital, which is good, because we don’t lose anything anymore, the quality is always uniform and high, and the images are available moments after the study throughout the entire hospital, including private offices and physicians’ homes,” says Reuben Mezrich, MD, PhD, chairman and professor of diagnostic radiology at the University of Maryland Medical Center (Baltimore). “The bad thing is it all gets in the way of communication between the referring physicians and me.”
Gone are the days when the radiology department controlled the dissemination of study images. Unfortunately, when referring physicians are able to access images without visiting the radiology department, they will do just that?altogether eliminating the discussions that often took place as the film was reviewed.
“We’ve lost that dialogue, and sometimes, a conversation about why a physician ordered a particular study is a good conversation,” Mezrich says. “The field is changing so fast, it’s important to know what information he’s hoping to obtain to find out what study is the best to order?is it a plain film, an MR, a CT, or a PET? This is where there should be communication, and we’ve lost it.”
But Mezrich is confident that technology can help remedy some of the ailments that it has created. Early this year, his radiology department will start a pilot program with a simple goal: to increase the flow of information throughout the facility.
The team will experiment with a variety of options to determine the best possible solution?or combination of solutions?focusing on wireless tools, including mobile phones, PDAs, laptops, and tablet PCs. Mezrich even brought in a few iPods. The plan is to use them to distribute informational videos?akin to Podcasts?relating to either specific patients or providing general educational information.
“We’re exploring and studying the best way to communicate,” he says. “After the trial in the department, hopefully sometime this summer or this fall, we’ll spread it around to the rest of the hospital.” In a culture where no one “owns” film?when, in fact, film is fading fast?Mezrich wants to make sure the radiologist’s role evolves and thrives.
“What is the value added from a radiologist now that images are sent around the hospital instantly?” Mezrich asks. “It is the intelligence we add to the image. If that isn’t there when the referring physician is providing care, then we’re not providing care; we’re doing quality control. We want to provide care, so we must have the best communication tools available.”
Mezrich and his team are making use of a myriad of options with technology from MobileAccess Networks Inc (Vienna, Va), which delivers in-building solutions for cellular coverage regardless of the wireless service providers.
Direct to the Patient
Clinicians are not the only ones who are benefiting from the technology boom. In the near future, mammography patients from the Westchester Medical Group (White Plains, NY) will have the option of completing their prescreening survey on a freestanding kiosk.
Using a touch screen, patients can complete a mammography questionnaire, which is reviewed by an assistant and then goes directly into the facility’s EMR system. After the exam is complete, images are attached to the report and are only a click away any time the patient’s record is accessed.
By automating this step of the process, it provides the opportunity for radiologists to interact with patient information in a completely new way.
“When a physician brings up the images to read a mammogram, he or she also launches the electronic medical note,” explains Simeon A. Schwartz, MD, president of The Westchester Medical Group, and clinical associate professor of medicine at Cornell University School of Medicine (Ithaca, NY). “In our PACS, when the report is sent to the EMR system, the image is included as an attachment, allowing any physician reviewing the X-ray reports to see the X-ray with a click of the mouse.
“Here’s what a radiologist is going to look like in the new world,” Schwartz continues. “On the left-hand side of the monitors, he or she will have the EMR and, in the case of mammography, the completed questionnaire. The report of the mammogram will go into the EMR when he or she signs it, and he or she will click the tracking system at the same time, which is in the note of the EMR. This process requires the physician to provide some information, such as the ‘next anticipated date’ and whether the findings were ‘normal/abnormal,’ among other details. This way, we have three things in one file: the report, the image, and proof that the radiologist reviewed the mammography form that was completed by the patient.”
A Rapidly Approaching Future
Andy Warhol once said, “They say that time changes things, but you actually have to change them yourself.” This statement is appropriate especially, it seems, for those on the forefront of imaging technology. Technology alone would not have the impact that proactive physicians and researchers are able to make, simultaneously increasing physician convenience and accessibility and, ultimately, improving patient care.
Improving Emergency Care
When treating critical patients, trauma teams are racing the clock. Fortunately, teams of medical professionals are working to make the tenuous “golden hour” obsolete.
“We are challenging the concept of the golden hour in a most serious way; we want it to be golden minutes,” says Rifat Latifi, MD, professor of clinical surgery, director of surgical critical care, and director of telemedicine for trauma and critical care at the University of Arizona Health Sciences Center (Tucson). “We used to have to wait for the patient to get to us, but now we are there, wherever the paramedics go. The trauma surgeon or emergency physician is virtually present and can intervene at any time.”
As part of a collaboration with the Tucson Fire Department, the first few months of 2006 will see ambulances and hospitals throughout the city equipped with streaming video devices that enable paramedics to communicate directly with physicians in the destination hospital. Vital signs also are monitored and displayed in the awaiting emergency department (ED). Some ambulances also are equipped with portable ultrasound systems, allowing paramedics to send images to the ED’s trauma team when requested.
Providing remote care is not new to the University of Arizona team. About a year ago, the team created a similar program in Douglas, a small town more than 100 miles away.
“If there is a trauma patient there, they get on the phone or on the computer, and we see exactly what they’re doing and how they’re doing it,” Latifi says. “We are able to tell them what they need to do to care for the patient.”
The Tucson-based system will feature more robust technology and will travel via the city’s infrastructure.
Once up and running, the workflow will be very direct. Paramedics at an accident scene will be able to send physiologic information?such as vital signs, waveforms, and ultrasound scans?as well as images back to the hospital’s ED using Rosetta. Created by General Devices (Ridgefield, NJ), this system links together the various instruments and communication means used in the ambulance. Information received in the ED is managed on a General Devices CAREpoint EMS Workstation that collects, displays, and automatically archives the data for the gathering response team.
“Once they’ve activated the system, we have a trauma doctor who staffs the command and control room,” Latifi explains. “We can monitor vital signs and see and talk to the patient; if necessary, we can have someone feel the patient, look at the wound?everything you would do if you were there physically.”
A similar project is under way east of Tucson, where Raymond Fowler, MD, FACEP, the deputy medical director for the EMS system for the city of Dallas and an associate professor of emergency medicine at the University of Texas Southwestern School of Medicine (Dallas), and his team are working to establish a real-time video capability on board ambulances in the Dallas area.
Also using a Rosetta/CAREpoint system from General Devices, Fowler has been able to demonstrate the ability to stream live video, live audio, 12-lead EKG, real-time EKG rhythm strip, waveform capnography, and pulse oximetry and blood pressure in real time?from the back of a moving ambulance.
At the time the feasibility study was completed, the wireless router network was not developed enough to allow seamless streaming from the field, according to Fowler, who plans on moving forward using wireless data cards.
“The wireless data card?for instance, the EVDO card?will very likely allow high data throughput,” says Fowler, noting that as much as 400k per second is required to send real-time video. “Thus, we must have a broadband connection that will enable us to seamlessly send the telemetry that we need.”
Although the vast majority of patients transported in ambulances do not require such close monitoring, having the technology available can be the difference between life and death for the estimated 2% to 5% of patients who need it, such as victims of stab wounds, gunshot wounds, and major accidents, or those suffering from prolonged cardiac arrest or acute myocardial infarction with arrhythmia.
The availability of real-time telemetry monitoring provides paramedics with another set of eyes to watch over unstable patients. Often, those eyes belong to the hospitals’ experts. In busy EDs, it is not uncommon for a bevy of physicians, nurses, and techs to help care for the desperately ill.
Real-time monitoring also gives the trauma teams time to prepare for the patient’s pending arrival. Instead of waiting to order an MRI upon the patient’s arrival, for example, the radiologist on call could be brought in to make such an assessment while the patient is still on the road.
Fowler would like this approach to be used throughout the entire city, at which point a centralized facility would be created to handle the increased workload.
“We believe the opportunity will come to develop regional telemetry-screening centers that will be online 24/7, staffed by medical agents able to assist the paramedics in rendering the evaluation and care that is necessary,” Fowler says. “It will be like a virtual emergency department, as well as a virtual information center, because you can do everything. You literally can put a stethoscope on the chest wall and hear breath sounds electronically. This certainly will be the future.”
Whether in Texas or the Arizona desert, the benefits are sure to extend beyond local citizens.
“What we are going to learn from this program is going to be adopted by others around the world?that is one of its biggest merits,” Latifi says. “The day will come that all Level 1 trauma centers are required to have a system like [the one we are employing]. My goal is for this system to not just be in Tucson, but in every helicopter and ambulance caring for patients.”
Dana Hinesly is a contributing writer for Medical Imaging.