1 EUROPEAN HOSPITAL’S SPECIAL ISSUE FOR THE EUROPEAN CONGRESS OF RADIOLOGY MARCH 2005 When we launched Selenia TM Full Field Digital Mammography, users said we had a winner. Selenia combines the very latest advances in technology with highly sophisticated information management capabilities. The result – a comprehensive digital solution for the mammography suite. The demanding practice of breast imaging requires specialized tools to simplify workflow and ensure effective and efficient case review. The Selenia softcopy workstation integrates a package of specialized tools that take into consideration special workflow needs to facilitate accurate, efficient review of digital mammograms. And, flexible image management capabilities support workflow, archival and retrieval requirements seamlessly. With so much going for Selenia, it's easy to see why Hologic full field digital mammography system can't be topped. To learn more, call 800.486.4656 or +1.781.999.7300 internationally. Visit us at www.hologic.com. Or send an email to [email protected]. Visit us at ECR Expo C Booth 302. Selenia. For technology, we’re at the top of our game. T he term moleculary medicine is increasingly heard. In diag- nostics, Dr Naraghi explained that this means the knowledge of moleculary causes for the develop- ment of diseases is used to prevent, or diagnose and treat those diseases at an early stage, which can be done with the help of laboratory diagnos- tics as well as imaging diagnostic pro- cedures, adding: ‘Molecular imaging plays a very strategic role.’ ‘Moleculary’ medicine: now and the future In an interview with Daniela Zimmermann, Executive Director of European Hospital, Dr Mohammad Naraghi, Head of the Department of Business Development at Siemens Medical Solutions, discussed developments in moleculary medicine, biochips, preventive diagnostics and a comprehensive and integrated health system for the future Data mining is another increasing- ly used term. ‘In the field of molecu- lary diagnostics data mining initially means the analysis of large amounts of data with the help of information technology and to look, for example, for genetic or other, clinical patterns that can signal potential disease,’ he explained. ‘To do this we need a high- ly efficient IT infrastructure. Modern medical diagnosis procedures, such as CT, MRI or, in the future, molecu- lary methods, produce rapidly increasing amounts of data. The chal- lenge is to analyse these intelligently and in an integrated manner so that we can extract clinically relevant, action-oriented information from them. However, this assumes that we can overcome today’s clinical data silos and establish integrated, elec- tronic patient files, ideally across cur- rent boundaries of care. ‘To recognise and visualise dis- eased processes through molecular interaction, molecular imaging needs molecular contrast media and radio- pharmaceuticals.’ Two distinctions are made for dis- ease diagnoses: in the first a patient already has a disease, in the other the patient is described as being predis- posed to a disease, for example developing breast cancer. ‘A predis- HISTORY: FROM HANDS TO MOLECULES continued on page 2 Some early popular concepts about the ability of X-rays to ‘see through things’ were not always off the mark in terms of what the future would hold. The old French postcard shown here depicts a customs officer checking out a trunk by using an X-ray device. The next images show how X-ray techniques revealed Mexican immigrants hidden in a lorry and man in a car boot. The lorry appeared in European Hospital in April 2004, when Professor Herman Vogel, Senior Medical Officer at the Albers-Schönberg-Institute for Radiation-Diagnostics, debated the current use of X-rays at country border controls in terms of radiation risk. The third image demonstrates the thrill of seeing the bones of a hand. Gradually, since the X-ray was discov- ered, more powerful scanners devel- oped, along with the computer, which combined to allow us to hone in on and clarify views of body parts - and far deeper. If Roentgen were able to return to life, wouldn’t he have been delighted by the advancement towards ‘seeing’ cells and thus targeting disease at a level certainly never imagined! At the ECR, try not to miss the exhi- bitions of ephemera as well as ‘Violence in X-rays’, which documents torture and crime in today’s world. Organisers: The German X-Ray- Museum in co-operation with Professor Vogel.
Transcript
1
EUROPEAN HOSPITAL’S SPECIAL ISSUE FOR THE EUROPEAN CONGRESS OF RADIOLOGY
MARCH 2005
When we launched SeleniaTM Full Field DigitalMammography, users said we had a winner. Selenia
combines the very latest advances in technology withhighly sophisticated information management capabilities.
The result – a comprehensive digital solution for the mammography suite.
The demanding practice of breast imaging requires specializedtools to simplify workflow and ensure effective and efficient case review. The Selenia softcopy workstation integrates a package of specialized tools that take into consideration specialworkflow needs to facilitate accurate, efficient review of digitalmammograms. And, flexible image management capabilities support workflow, archival and retrieval requirements seamlessly.
With so much going for Selenia, it's easy to see why Hologic full field digital mammography system can't be topped. Tolearn more, call 800.486.4656 or +1.781.999.7300
internationally. Visit us at www.hologic.com. Or send an email to [email protected].
Visit us at ECR Expo C Booth 302.
Selenia.
For technology, we’re at the top of our game.
LORAD® BREAST IMAGING SOLUTIONS
The term moleculary medicine
is increasingly heard. In diag-nostics, Dr Naraghi explainedthat this means the knowledge
of moleculary causes for the develop-ment of diseases is used to prevent,or diagnose and treat those diseasesat an early stage, which can be donewith the help of laboratory diagnos-tics as well as imaging diagnostic pro-cedures, adding: ‘Molecular imagingplays a very strategic role.’
‘Moleculary’medicine: nowand the futureIn an interview with Daniela Zimmermann, Executive Directorof European Hospital, Dr Mohammad Naraghi, Head of theDepartment of Business Development at Siemens MedicalSolutions, discussed developments in moleculary medicine,biochips, preventive diagnostics and a comprehensive andintegrated health system for the future
Data mining is another increasing-ly used term. ‘In the field of molecu-lary diagnostics data mining initiallymeans the analysis of large amountsof data with the help of informationtechnology and to look, for example,for genetic or other, clinical patternsthat can signal potential disease,’ heexplained. ‘To do this we need a high-ly efficient IT infrastructure. Modernmedical diagnosis procedures, suchas CT, MRI or, in the future, molecu-lary methods, produce rapidlyincreasing amounts of data. The chal-lenge is to analyse these intelligentlyand in an integrated manner so thatwe can extract clinically relevant,action-oriented information fromthem. However, this assumes that wecan overcome today’s clinical datasilos and establish integrated, elec-tronic patient files, ideally across cur-rent boundaries of care.
‘To recognise and visualise dis-eased processes through molecularinteraction, molecular imaging needsmolecular contrast media and radio-pharmaceuticals.’
Two distinctions are made for dis-ease diagnoses: in the first a patientalready has a disease, in the other thepatient is described as being predis-posed to a disease, for exampledeveloping breast cancer. ‘A predis-
HISTORY: FROM HANDS TO MOLECULES
continued on page 2
Some early popular concepts about theability of X-rays to ‘see through things’were not always off the mark in termsof what the future would hold. The oldFrench postcard shown here depicts acustoms officer checking out a trunkby using an X-ray device. The nextimages show how X-ray techniquesrevealed Mexican immigrants hidden ina lorry and man in a car boot. The lorryappeared in European Hospital inApril 2004, when Professor HermanVogel, Senior Medical Officer at theAlbers-Schönberg-Institute forRadiation-Diagnostics, debated thecurrent use of X-rays at country bordercontrols in terms of radiation risk.
The third image demonstrates thethrill of seeing the bones of a hand.Gradually, since the X-ray was discov-ered, more powerful scanners devel-oped, along with the computer, whichcombined to allow us to hone in on andclarify views of body parts - and fardeeper. If Roentgen were able to returnto life, wouldn’t he have been delightedby the advancement towards ‘seeing’cells and thus targeting disease at alevel certainly never imagined!
At the ECR, try not to miss the exhi-bitions of ephemera as well as‘Violence in X-rays’, which documentstorture and crime in today’s world.Organisers: The German X-Ray-Museum in co-operation withProfessor Vogel.
position shows the likelihood ofdeveloping a disease, which can havegenetic causes. Certain combina-tions of genes, for example, have avery high likelihood of resulting incancer or other diseases. If a patienthas a certain combination of genes,which, in many other patients, hasbeen confirmed as a trigger for a cer-tain illness, he has a very high pre-disposition. The other subject is thediagnosis of a disease that is alreadyestablished, with the help of molecu-lar-medical methods - and to do thisearlier than currently done. In addi-tion, gene-technological methodswill also be used for the recognitionof predispositions. In some cases wecan definitely determine that a dis-ease has genetic causes, for examplecystic fibrosis and other diseases,such as Huntington’s.
In predisposition, the professorpointed out that one of the big chal-lenges is to determine in what ways apatient is likely to develop a disease,
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whether or not it progresses andover what period of time. ‘At themoment there are no recorded pro-cedures for this. What we can say isthat, if a predisposition exists, a dis-ease is likely to develop over a cer-tain period of time with a certain sta-tistic probability. However, we musttake into account that all diseasesare different, and won’t necessarilydevelop. From a purely statisticpoint of view we can determine theaverage probability of the diseasedeveloping. For instance, the proba-bility for a woman to develop breastcancer at some stage in her life is xpercent. Then we can say that if awoman has specific genes in a modi-fied form often known to trigger can-cer then the probability of her devel-oping the disease at some point inher life is not x percent but possibly3x or 5x percent. However, once youhave established that someone has ahigher probability of developing thisor that disease you can screen andmonitor so that, if the diseases actu-ally develops, we can start therapy ata very early stage.’
In the case of breast cancer, forexample, although this scenariocould be quite comforting for statis-ticians, wouldn’t it scare women interms of its predictability and then atwhat stage in life it would occur? DrNaraghi concurred, but pointed out:‘Thanks to moleculary diagnosticswe will have very efficient methodsat our disposal in the future to recog-nise the occurrence and progress ofdiseases. Depending on their predis-
positions, doctors are able to recom-mend that patients be screened andmonitored on a regular basis. If thedisease then actually develops, thediagnosis can be made at a very earlystage and therapy will be much moresuccessful if commenced early.Surely this brings us one step fur-ther!’
This could also mean a significantcost-saving potential from a commer-cial point of view. ‘The largest blockof costs arising in the healthcare sys-tem today develops because manydiseases are diagnosed too late, andthen the system has to bear the costsof coping with the long-term conse-quences,’ he replied. ‘Let’s look atoncological, neurological and degen-erative diseases and, for example,the fact that a high percentage ofcolon cancer cases can be diagnosedand it can be removed at an earlystage with the help of endoscopy andother methods. Molecular diagnosiswill enable us to recognise these dis-eases at an even earlier stage of theirdevelopment. And this will, again,save costs and dealing with the long-term effects of these illnesses. Weare hoping, for instance, to diagnoseAlzheimer’s at an early stage beforethe whole range of clinical symptomsmanifests itself. And if we then alsohave medication available, which atleast slows down the process of theillness, we would enhance a patient’squality of life a lot. It would also haveenormous economic effects because,for instance, we could save on costsfor long-term care.
Returning to the discussion oncontrast media, used in combinationwith different imaging diagnosticprocedures such as PET, SPECT,MRI, we asked which procedure isused in which cases? ‘It very muchdepends on the disease. PET-CT isoften used in the case of oncologicaldiseases. MRI is the preferredmethod for neurological problems,and we use CT and SPECT for car-diac problems. There are many dif-ferences, and we have long-term clin-ical experience of which methodsshould be used in which case.’
What’s the difference between Aquasonic® 100and those other gels?Clarity, reliability, and economy.
Aquasonic 100 Ultrasound Transmission Gel
The clarity that sonographers havecounted on for over 40 years.
However, Dr Naraghi pointed outthat truly molecular contrast mediais as yet unavailable. ‘They are at theearly stage of development. So wecannot yet say what the conse-quences will be in every single case.But it is likely that innovations in thearea of contrast media and progressin the area of molecular medicine ingeneral will change and enhance theuse of different methods of imagingdiagnosis.’
Contrast media generate a newconnection between medicine tech-nology and the pharmaceuticalsindustry. To highlight this, wereferred to the GE acquisition ofAmersham, and asked aboutSiemens’ views on potential opportu-nities. ‘Our strategy is to offer solu-tions that help our customers toimprove the quality of care and tolower costs - to increase efficiencythrough innovations and processoptimisation When putting thesestrategies into practice we not onlythink about single segments of thehealthcare system but about itsentirety. We talk about integratedsolutions, which comprise all areas -prevention, diagnosis, therapy andcare. Based on this background wecontinually work out how theseobjectives can be realised. Wherenecessary we will enter into theappropriate co-operations and part-nerships. In the area of molecularmedicine, and contrast media in par-ticular, we think that many innova-tions will not come from one singlecompany but from a whole range ofinnovative companies, larger andsmaller institutions, research facili-ties and hospitals. This means thatwe are more likely to be thinkingabout partnerships and co-opera-tions in this area.
When did he think the first, trulymolecular contrast medium mightbecome available? ‘This is difficultto say,’ he replied. ‘It will take a fewyears and will also depend on thereadiness of the regulating bodies inthe US, Europe and elsewhere tofacilitate faster licensing proce-dures.
Ferrania demostrates a wide range of digital and web-based solutionsincluding LifeWeb, a web-based radiology information system and picturearchiving and communication system (RIS/PACS), LifeInVision, a digitalacquisition system and the new range LifeImager 6000 DICOM enabledimagers. The LifeWeb RIS 2.1 is an enterprise-level RIS system that pro-vides a complete set of tools to manage the radiology workflow. Utilisingnative web technology as a framework, LifeWeb RIS provides an open andflexible architecture in which integration of a “brokerless” PACS and RIScan occur. A robust composition of patient records and images is effi-ciently obtained through the combination of an intuitive user interface anda DICOM structured reporting module – making possible the convergenceof both reports and images within the same DICOM hierarchy.
RIS / PACS in Italy and the UK
Also featured on the Ferrania stand will be the University La Sapienza –Policlinico Umberto 1 installation in Rome – both the Radiology andNeuroradiology departments – plus the recently commissioned innovativeRIS / PACS installation at Newcastle Upon Tyne NHS Trust in Newcastle,UK. As with the Rome installation a key factor for Dr Andrew Chippindale– Clinical Director of Radiology – and Phil Wilson – Radiology DirectorateManager for the Trust – was the availability of images on-line throughoutthe 4 sites spread across Newcastle city centre. Quite a challenge with over1000 examinations per day, some 5.5 million images per year being gener-ated, and needing to be available throughout 13 departments, often simul-taneously at different sites. To date there are over half of the 5000 Trustusers on line. For more information please see us at booth 108 hall A.
RIS/PACSInnovations
at the ECR 2005
New contrast agents known as SmartContrast Agents are at the core of theresearch in the area of MI.
continued from page 1
New concept in hybrid imaging technology
Molecular medicine is arrivingas a blizzard of new genesand their proteins. (Eachgene instructs a cell toproduce or ‘express’ a
protein. Abnormal cells are thosewhose genes are over or under-expressing a protein, or expressing anabnormal protein. The sheer numberof newly discovered genes andproteins will almost guarantee an evermore detailed understanding ofhuman biology and disease, and leadto many new drug molecules thatinteract with the new entities, andincreasingly interact specifically withonly abnormally operating cells. Inmost cases there will be multiple newdrugs that work specifically onsmaller subsets of diseasedindividuals.
Wherever regionally definedbiochemical information is useful,there will be fertile ground for newimaging agents, for it is regionallysorted information, obtained non-invasively, that is the strength of invivo medical imaging. Imagingpharmaceuticals of the future willyield regional protein expression -regional proteomics. Nuclearmedicine (NM) already has provenability to image regional proteinexpression, for example, usingPositron Emission Tomography (PET)to find highly metabolic metastases inmany cancers. ‘Targeted biochemicalimaging’ will also be crucial topredicting the outcome ofbiochemically specific therapeuticinterventions. While diagnostics -finding a disease - will be greatlyassisted by highly anatomical imagingmodalities like MRI and X-ray CT,characterizing the disease throughprotein expression imaging willrequire extreme sensitivity, currentlyavailable with NM. Prognostics, ratherthan diagnostics, is a broader term forthe future role of NM.
Ultrasound (US) can possibly copewith protein expression when thetargets of the US imaging agent areaccessible to the contrast agents, andthere is a long-term possibility evenfor MRI agents. Current technology inthese latter imaging modality’s agentsrestricts agents to large sizes andtherefore to targets expressed insideblood vessels. NM agents can be madevery small, to pass through bloodvessel walls and they can then accessabnormal cells other than thosecontacting the blood - and mostabnormal cells are of that type.
Bracco Research USA Inc, focuseson generation of targeting agents fordiagnostics, prognostics andradiotherapy, by designing andproducing biochemically specificelements of NM, MRI and US contrastagents. These biochemical elementsare the novel targeting molecules thatare attached to and carry diagnosticor radiotherapeutic molecules toabnormal cells. For example, aradioactive targeting molecule ‘homesin’ by attaching specifically to the
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Contrast agentsR&D at Bracco’s laboratories
abnormal proteins expressed only bythe abnormal cell, carrying theradioactive element with it.
Nuclear Medicine includes bothdiagnostics/prognostics and targetedradiotherapy. This latter technologyis a new variant of the most commoncancer radiotherapy - a radioactivebeam directed at whole segments ofthe body. Targeted radiotherapydelivers the radiation morespecifically to the target bycombining a targeting molecule witha radioactive element that emits a
killing radiation, and injecting thisnew molecule as a drug. Thetechnology involved in both forms ofNM, diagnosis/prognosis andradiotherapy, is intimately related.
Bracco has many years ofexperience in the necessary arts andsciences, numerous renownedexperts and PhD level scientists, andhas established criticalcollaborations with other companiesto enhance its capabilities andopportunities in this area. Source: Bracco Research USA Inc
Generating targeting agentsfor diagnostics, prognosticsand radiotherapy, bydesigning biochemicallyspecific elements in contrastagents to be the targetingmolecules attached to andcarrying diagnostic orradiotherapeutic moleculesto abnormal cells
As peoplewalked throughour stand at theRSNA inNovember, theycould see lots ofinnovations: theVolume CT, highdefinition MRand PET CT,which is still
tremendous - particularly for oncology.Additionally we have women’s health-care - digital mammography as well assome new technologies, such as newlydeveloped ultrasound technology forbone density diagnoses.
As we advance, one of the mostexciting things about GE Healthcare isits vision for the next twenty years,which we see as personalised health-care. If you look at that vision it coverseverything from predicting or statingthe disposition of disease, to muchearlier diagnoses, then to sharinginformation across geographicallyspread users, then, lastly, more target-ed therapies.
Let’s return to women’s healthcare -
one of the vigorous examples is oncol-ogy and breast cancer. Breast canceris obviously one of the predominantcancers for women and looking at thattoday, most women go through stan-dard mammograms. But we now knowthat if someone over-expresses a spe-cific genotype the chances of havingcancer are much higher and it could bediagnosed at a much earlier age. So asGE Healthcare advances - which, again,is to do with the conjunction betweenchemistry, biology and imaging - could-n’t we start to look at new technolo-gies that could help to tackle the wholedisease area of breast cancer? Withour customers, we don’t just talk aboutthe modalities or the specific technolo-gies, but about disease management,such as oncology. So, those are thekey messages right now - only GE hasthese capabilities, across that span.This is the new age of medicine.
As we brought the companiestogether, and went from being a diag-nostic imaging company with IT to acompany that provides personalisedhealthcare, the reactions we had inAmerica, Europe, the Middle East and
In May 2004, Kodak participated in aCSC-led alliance that was awarded a10-year contract with the UK NationalHealth Service (NHS) for deliveringdiagnostic imaging services for a sub-stantial portion of England. Under thecontract, the alliance is designing,building delivering and operating newPicture Archiving andCommunications System (PACS)across the North West and WestMidlands cluster.
The system is being established aspart of the Department of Health’s £6billion National Program for IT (NPfIT)aimed at helping millions of patientsto receive treatment more quickly andefficiently. The programme has fourprimary goals: an electronic appoint-ment booking system, an electroniccare records system, electronic trans-mission of prescriptions, and a fast,reliable underlying IT infrastructure.
Gary Larson’s presentation will con-centrate on some of the uniqueaspects of this programme that differ-entiate it from the delivery of a moretraditional PACS. ‘Together with otherparticipants in the alliance,’ he says,‘we are delivering a managed servicefor diagnostic imaging that is tightlycoupled with the overall core servicesin the NPfIT. Using KODAK DirectviewVersatile Intelligent Patient Archive(VIParchive) technology, we are deliv-ering a single, data centre-basedarchive for a population of approxi-mately 12 million patients. Finally, inaddition to KODAK Directview andDryview printing solutions, KODAKRIS 2010 is being used to electroni-cally integrate the radiology workflow
across hospitals in thecluster to optimise theutility of their assetsin the delivery.’
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Gary Larson,of the EastmanKodak Company,ProgrammeDirector forthe NationalProgrammefor IT
Don’t miss this!At the ECR, Gary Larson,
of the Eastman Kodak Company,will deliver a presentation on the
UK National Programme for IT:delivering Diagnostic Imaging for
the North West and WestMidlands in England
GE Healthcare announced at theRSNA in November that its next-generation volume computedtomography (VCT) scanner, theLightSpeed VCT, has set therecord for fastest volumetric imag-ing in the world. ‘The LightSpeedVCT with its .35-second rotationand 40-millimetre coverage allowsfor true volumetric scanning of theheart in only five beats.’
According to W Dennis FoleyMD, chief of Digital Imaging atFroedtert Hospital in Milwaukeeand professor of radiology at theMedical College of Wisconsin, theLightSpeed VCT’s new 35-secondrotational speed produces excellentresolution and coverage of theheart simultaneously: ‘It’s some-what amazing that an accurate 3-dimensional image of the coronaryarteries and sites of focal diseasecan be obtained from a beatingheart. The LightSpeed VCT system
Breaking the volumetric imaging record
Lightspeed VCT scanner
does this using rapid high resolu-tion imaging gated to the patient’sheart cycle.’
The first LightSpeed VCT wasinstalled at Froedtert Hospital inJune 2004 to provide insight intothe best clinical practices foradvanced CT systems, includinginformation to help with the diag-nosis of disease and injury.LightSpeed VCT is the onlyproven 64-channel detector in theworld, and can cover the anatomywith the fastest speed while simul-taneously providing the best reso-lution, GE points out.
Noting that LightSpeed VCT is75% faster scanning than existingCTs, Popular Science Magazinechose it as ‘The Best of What’sNew in Technology for 2004’.
‘This is game changing technol-ogy that will make the LightSpeedVCT the quintessential emergencyroom scanner,’ emphasised PeterArduini, general manager ofFunctional Imaging andComputed Tomography at GEHealthcare.
Due to its exceptional coveragespeed, the LightSpeed VCT hasthe capability to attain 43 millisec-ond temporal resolution, whichmeans doctors can effectivelyfreeze the motion of the heart,which might lead to a more accu-rate diagnosis and treatment ofheart disease and other life-threat-ening illnesses, GE added. In a sin-gle rotation, the system creates 64submillimetre images, totalling 40
“The most inspiring and exciting thingabout GE’s business is what the cus-tomer can now see under one roof: wecan deliver practically everything inimaging and services for the core radi-ologist because, with the acquisition ofInstrumentarium, our information tech-nology became much bigger in terms ofPACS, and through our acquisition ofAmersham, the inclusion of chemistryand biology completes our healthcareservices. It’s all in one family. GE isnow a company that represents about14 billion dollars in healthcare. Wehave around 402,000 employees -12,000 based in Europe. This is up byover 50% since 2003.
Acquisitions expand healthcare offerings When GE acquired Amersham,
the world’s biggest MedicalImaging Company, it connected
the fields of pharmaceutical withimaging technology production.
In an interview with Steve Bolze,President of GE Healthcare
International, we asked how thiswill influence GE’s strategy and
research and development
millimetre of anatomical coverage,which are combined to form a 3-Dview of the patient’s anatomy forthe physician to analyse.
LightSpeed VCT is able to noinvasively capture the heart in fivebeats and scan the whole body in10 seconds.
Identifying advanced procedurepossibilities 5-Beat Cardiac - Heart motion hashistorically made CT cardiovascu-lar scans challenging and prone tomotion artifacts. Due to its speed,the LightSpeed VCT is enablingphysicians to secure extremelyhigh-quality images of coronaryarteries at submillimetre resolutionin only five beats of the heart. Thisenables a fast and less invasivediagnostic evaluation of arterialstenosis.Triple RuleOut - In the A&E,patients exhibiting acute chest paincould be diagnostically scannedquickly and non-invasively, using
the extent of damage, and can helpmake this complex procedure easi-er and more routine.LightSpeed VCT and PET - TheLightSpeed VCT can be easily inte-grated with its positron emissiontomography (PET) technology,which will marry the high-speed,high-resolution capabilities of GE’svolumetric CT with the metabolicand physiologic capabilities ofGE’s PET.
PLUS - the first highdefinition MR system At the RSNA, GE Healthcare alsolaunched ‘...the world’s first highdefinition magnetic resonance(HDMR) system’. The firmreported that HDMR will, for thefirst time, provide physicians withunprecedented image clarity incases where patients are difficultto image due to movement, includ-ing Parkinson’s patients who sufferfrom uncontrollable patientmotion and including childrenwho do not respond to sedation.
Dr Lawrence N Tanenbaum,Section Chief MRI, CT andNeuroradiology, New JerseyNeuroscience Institute, said:‘Dedicated high density coils facili-tate throughput and enable highdefinition scanning, resulting indramatic images reminiscent ofthose provided by high definitiontelevision.’ This provides a ‘can’tmiss’ quality in challenging cir-cumstances, he added.
‘The technology dramaticallyimproves MR imaging speed andquality, allowing clinicians toobtain vast amounts of data in ashort time and to perform MRstudies that otherwise would becompromised,’ said Dennis Cooke,GE Healthcare’s Vice President,Global MR business
According to studies, 25-30% ofall head MR studies are compro-mised by some amount of patientmovement, which can impact onpatient diagnosis. However, theHDMR technology, Propeller pro-vides uncompromised images ofthe brain despite patient motion,
the firm pointed out. ‘HMDR willmake a real difference in patientdiagnoses by providing GE exclu-sive applications that enable physi-cians to consistently perform thehighly targeted studies they’vebeen wanting to do, but couldn’tbecause of patient motion or thechallenge of diabetic patients withlower blood flow to the lowerlegs,’ Denis Cooke added.
Also, because HDMR hasextremely fast image processingtechnology, it enables a greaterrange of targeted MR studies incritical areas such as the heart,liver and lower legs.
This new technology, availableon GE Signa 1.5T and 3.0T MRsystems, enables massively simulta-neous imaging in multiple channelsin increments of 16. HDMR fea-tures unique, balanced acquisitionarchitecture, with individualreceiver channels connected todedicated reconstruction engines.
As channels are added (in unitsof 16, 32, 48, 64 and more),image-processing power increasesin proportion, the firm explained.‘The coil elements that detect thesignal, the receivers that digitise itand the array processors that per-form calculations are scaledtogether so that massively simulta-neous imaging can be performedwithout image processing delays.This technology sets a new stan-dard for acquisition, gradients andthe human interface.’
GE’s Excite technology hasenabled three targeted MR appli-cations with meaningful clinicalbenefits: Vibrant for bilateralbreast imaging in a single exam;Tricks for MR angiography of thelegs; and Propeller for high-qualitybrain imaging that is extremelyresistant to motion artifacts.
New targeted studies:● Extremely high-resolutionimages of the liver with shorterbreath holds and better organ cov-erage ● MR Echo real-time cardiacimaging with the resolution of MRat the speed of ultrasound, with-out the need for breath holding orECG gating● A new 32-element peripheralvascular coil, providing images ofthe lower leg and foot vessels thatshow unprecedented definition
the LightSpeed VCT, for evidenceof heart attack, pulmonaryembolism or aortic dissection, thethree most life-threatening causesof chest pain, in a single scan. Stroke Work-Up - Once a strokeoccurs, it is commonly believedthat treatment must be deliveredwithin an hour, or less, to ensurethe best outcome. Current diag-nostic imaging procedures arecomplex. GE pointed out thatLightSpeed VCT offers the speedand resolution required for rapidexamination of blood vessels inthe brain (perfusion studies),enabling doctors to make a quickdiagnosis of stroke and determine
Asia were very positive. Certain areasof the world are responding more to IT,or biology, or chemistry areas, which ishow certain markets develop, but,overall and particularly during the first3-4 months, we had a tremendouslypositive response. What we have likedmost in discussions with customers isthat we’ve moved from being diagnos-tic imaging and modality specific toprediction and personalised health-care.
Due to acquiring pharmaceuticals,we now also have a greater relation-ship with general practitioners, and wealso need, in terms of personalisedhealthcare, to support various insur-ance activities - a productivity vision,which is a much broader concept.Insurance companies want to savemoney, it is a key interest - particularlyin Europe right now. We have a busi-ness area with services called per-forming solutions, in which we areworking with customers on improve-ments. For example, say they have anew diagnostic imaging project. Theyask: How can we scan more patientsand improve the hospital’s productivi-ty? How can we plan therapies and thehospitals workflow? In Europe, a lot ofattention is given to these questions. “
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From left: Prof J FRiemann and Dr G Layer
Calling for radiologists to coordinate acomprehensive prevention campaign,Hans-Ulrich Kauczor, professor of oncol-ogy diagnostics and therapy atHeidelberg University and head of radi-ology at the city’s Cancer ResearchCentre, described the potential for thispresented by advances in magnetic res-onance imaging (MRI) systems.
Professor J F Riemann, director ofMedical Clinic C, in Ludwigshafen, con-curred, adding that, although colorectalcarcinoma causes the second largestnumber of cancer deaths after bronchialcarcinoma, the German public’s interestin primary prevention is low. This, hesaid, makes preventive measures, i.e.early detection of polyps and carcinoma,even more important. ‘Due to the lowsensitivity of the occult blood test andhigh incidence of undetected lesionsduring sigmoidoscopy, coloscopy is nowthe preferred screening procedure,medically and financially.’ An Americannational study on polyps clearly showedthat consistent polypectomy for theearly stages of cancer prevented thedevelopment of colorectal cancer in upto 90% of cases, he said. Thus, fromOctober 2002, coloscopy has beenincluded in the German medical insur-ers’ early cancer screening programme.
At the 11th International MR Symposium radiologists wereurged to co-ordinate a campaign to
detect disease earlier,and a new ‘tandem’
concept for diagnosisand therapy was
revealed. AnjaBehringer reports
Dr G Layer explained that, since2001, an interdisciplinary working groupat Medical Clinic C and the CentralInstitute for Diagnostic andInterventional Radiology, had beenworking on an intensive diagnosis ofgastroenterological diseases, and thatthis rare German example of ‘coopera-tion not confrontation’ has resulted inthe establishment of MRI in routine gas-troenterological diagnosis.
In view of the low public interest incolorectal cancer screening, specialistsnow wonder whether the additionaloffer of modern imaging procedureswould generate more interest in thispreventive care. Previously, a completedepiction of the colon was only possiblevia computed tomography (CT).Depending on the method used, thisscreening system offered a sensitivity ofover 90% for polyps larger than 1cm,but it exposes a patient to a certainamount of radiation - and early screen-ing programmes also include those whoare clinically healthy.
Due to further developments in MRI,colonography is now possible withoutradiation exposure. ‘However, this type
of screening is still in its early stagescompared with CT-colonography,’ saidDr Layer. ‘It needs further evaluation inprospective studies.’ The underlyingformula seems to be what’s been said inthe USA: ‘MRI is good for healthy peo-ple, CT is good for those who are sick’.
The latest project at theLudwigshafen Clinic is virtual imagingof the large intestine, as well as exami-nation of the biliopancreatic system andsmall intestine. In this the patient iscared for by radiologists experienced ininterface imaging diagnostics who sharetheir endoscopic expertise with expertsin gastroenterological diagnostics andtherapy. ‘If existing methods are to beimproved and new procedures devel-
oped, the potential of MRI in diag-noses in this area can only be effec-tively utilised through cooperation,’said Dr Layer, who has developed,with Prof. Riemann, what they callthe ‘tandem’ concept - which worksdue to their close cooperation in theirfields of expertise.In tandem - coloscopy is combinedwith diagnostic procedures such asMRI colonography, thus bringing thenumber of unpleasant examinationsfor a patient to a minimum and savingtime for all involved. Those who comefor colon cancer screening and arefound to have no gastrointestinalsymptoms are offered an MR colonog-raphy, after receiving initial consulta-tion and advice. If polyps or any otherpathological problems are detected, atherapeutic coloscopy follows.
The professor went on to present aconcept in which radiology could beused for secondary prevention. In this, anew ‘preventive’ radiologist would headan interdisciplinary medical team tocare for a patient. However, he conced-ed that the economic benefits of such asystem must still be considered.
Secondary prevention is about identi-fying the early stages of a disease, forwhich risk factors are present but thereare either no symptoms or non-specificsymptoms. This presents the radiologistwith much to examine, and for that themethod of choice is virtual coloscopy ofthe large intestine, to detect polyps ortumours. Other possible indications:cardiovascular and neurodegenerativediseases and their differential diagnosis,plus various metabolic risk factors.
Pushing for prevention
6
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Prof. Alexander Tschammler credits the full field digital mammography system and stereotacticbreast biopsy table with helping the institute to optimise efficacy and efficiency
Germany - At the Institute ofRadiology, University of Wurzburg,patients can undergo mammography,receive results and schedule a biopsy- all on the same day. The Institute,which annually carries out 6,000mammograms and 350 biopsies,began streamlining its process in2003, with the installation of aHologic MultiCare Platinum breastbiopsy system. This was chosen fortwo key reasons, explained ProfessorAlexander Tschammler, chiefphysician in the Institute’s breastimaging department: the patient isprone which minimizes movement,and the system facilitates biopsyfrom above, below or either side,enabling the breast to be reachedfrom any angle. ‘I try to enter thebreast from below,’ he added. ‘Thatway, if there’s a scar, no one will seeit.’
Because Germany does not yetallow digital screening - a situation
expected to change in 2005 - a fewmonths later the Institute alsopurchased a conventional HologicM-IV system to replace the analoguemammography system used therefor many years. The professorexplained that the change inmanufacturers was made becauseHologic’s analogue and digitalsystems are very similar, making it
Streamlining mammographyAll in a day: screening, results and a biopsy booking
easy for technologists to switchbetween either, and servicing by justone company proved moreattractive - a Hologic supporttechnician was within easy distance,ensuring speed if any changes to thesystem should be needed.
Last year the university also optedto install a Hologic Selenia full-fielddigital mammography system, achoice made not only forconsistency, but also because,among the full-field productsavailable, in slot scanningtechnology the scan times were toolong, and among the flat-panelequipment on offer, either the fieldof view was far smaller thanSelenia’s 24 x 29 cm FOV, or theydid not have a mature systemsolution worth evaluating, Prof.Tschammler said, adding: ‘Thelarger field of view is absolutelynecessary. A third of our patientsdon’t fit on an 18 x 24 device.’ In
Belgium - Radiologists at the Departmentof Medical Imaging at AZ Sint-Maartengeneral hospital, Belgium, will be able toreport from home during weekends ornight duty periods, when a new PACS sys-tem is installed at the hospital. Currentlythe ten radiologists per form around80,000 radiology examinations annually. To integrate radiology services at its twosites - Duffel and Mechelen - the hospitalhas ordered Agfa’s picture archiving andcommunications system Impax. MR exam-inations are performed in one site. Byusing the WEB1000(tm) web server inter-face, the new system will enable diagno-sis in both, speeding up reports and liai-son with physicians. The Impax at AZ Sint-Maarten will be inte-grated with Agfa’s RIS and speech tech-nology solutions and connect with themedical patient record. The IMPAX solu-tion will be installed at one site and con-nected to the other via a 100 Mbps line.Reports will be made from nine ImpaxDS3000 diagnostic display stations,spread over both sites. An outpatient CD-ROM-burning solution will be available ateach site. The hospital’s Medical Imaging depart-ments will also be equipped with Agfa’sCR 75.0 and CR 25.0 digitisers. Apartfrom mammography, all imaging activitieswill then be fully digital, with data flowingthrough the relevant departments as wellas any authorised home-based radiologist.
Belgium - Barco has received 510(k) pre-market clearance from the USA’s Foodand Drug Administration (FDA) for itsVoxar 3D VesselMetrix module, whichoffers radiologists a vessel analysis pack-age to evaluate contrast-enhancedComputed Tomography Angiography (CTA)and Magnetic Resonance Angiography(MRA) studies in the assessment ofstenosis, stent and stent graft planning,and stent graft surveillance.
The FDA 510(k) clearance, in February,arrived soon after the company first pre-viewed the software at the RadiologicalSociety of North America (RSNA) confer-ence in November, when Craig Anderson,General Manager of the Voxar productgroup, observed its good reception: ‘Ourcustomers and PACS partners need 3D-enabled clinical software applicationsthat are user-friendly and optimised toincrease productivity. VesselMetrix deliv-ers this for angiographic studies and isfundamental to our goal of providing radi-ologists with the tools they need to effec-tively read large volumetric data studies.’
Barco designs and develops solutionsfor large screen visualisation, displaysolutions for life-critical applications, andsystems for visual inspection.Headquar tered in Kor trijk, Belgium,Barco has facilities in Europe, NorthAmerica and Asia Pacific, for R&D andmanufacturing, plus sales & marketing,customer support.Details: www.barco.com
ANGIOGRAPHY READINGSFROM HOME
Above: 3-D colour volume image showing an endovascular repair of an AAA(Brigham and Women’s Hospital, MA)Right: MPR localiser view of a straightened vessel of an AAA displaying thecentreline through the lumen
FDA clears CTA and MRAvessel analysis package
addition to accommodating largerbreasts and providing overall greatimages, the Selenia is alsocompatible with the hospital’s newPACS system - the entire state-of-the-art imaging/biopsy/imagetransmission capability will goonline early this year.
In terms of digital vs. analogueimage quality, contrast in the former
is better for visualisation ofcalcifications and architecturaldistortion also is more easilyvisualized, he pointed out, addingthat the radiation dose has beenreduced by about 10% with thedigital system, largely because theimproved ability to manipulatedigital images has reduced the needfor magnification and other
additional views. Another advantageis that digital images are producedfar more quickly than film imagesand, if they request it, patients canbe given their images on a CD.
However, for now, Germany offersinsufficient reimbursement to coverthe additional costs involved in afull-field digital screening system.‘When digital screening is
reimbursed, and when the cost ofsystems comes down, its impact willreally begin to be felt,’ the professorpredicted. That is, conventionalmammography systems will not beneeded. ‘Image characteristics ofdigital mammography and biopsysystems are similar, so it’s easy to gofrom digital mammography to digitalbiopsy. The future is digital.’
7
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industry notebook equipped with specialsoftware - which we supply. We calibratethe high-end display. The notebook canonly be customised for medical useby these additional steps. In theo-ry,’ he added, ‘data are transfer-able into all radiography modali-ties, but the system’s use is opti-mised for CT and MRI; that is,the software interface and thenotebook display are optimisedfor use in interface diagnostics,’
Gregor Wedekind MD (right) offersradiological services to the local hos-pital and outpatients in Kempen, acity in the West Ruhr Area ofGermany. Having searched for amobile radiology system for sometime, he has opted for a new teleradi-ology system called MORITS. Thisutilises high-resolution laptops toreceive transmitted images obtainedduring a medical emergency, so thatradiologists situated virtually any-where can supply a diagnosis.
During a recent interview with ourjournal, Dr Wedekind presented ascenario to explain its use: ‘A privateradiology practice works with a hos-pital that has no facilities for inter-face diagnostics. However, when thepractice is closed for the night, orover weekends, no one is using itscostly and very useful equipment,which amounts to about 75% of thetime. To provide the hospital withemergency cover someone has to beat the practice to make a diagnosis.However, with only three availableradiologists, this would boil down to10 nights of cover for each radiologistper month - and more during holidayperiods. Hence we had to find a solu-tion and began to focus on teleradiol-ogy - available for quite some timeover a fixed network. In this, data hasbeen transferred from a CT scannervia a fixed network line to a PCinstalled at home - but again, theradiologist must be stationed athome. So, we looked for a solutionthat facilitates total mobility - andeventually we found it.
‘Major providers, whether film sup-pliers or firms specialising in medicaltechnology, had no solution to matchthis concept. On the contrary, theyeven disputed that something likethis could be developed. Anyhow, wehave done it and it works. The licens-ing procedure, with the Health andSafety Office in North-RhineWestphalia, was another story... butapproval for its use was receivedafter radiology experts examined theequipment and deemed it serviceable- a great relief. Knowing that I canaccess my images from any locationis very reassuring.
‘You can work from absolutelyeverywhere because transmission isvia UMTS and, if there is no UMTSreception, it automatically switchesback into the GSM network, whereseveral channels are bundled. It basi-cally works everywhere a normalmobile telephone works. This com-plies with the new regulations on tel-eradiology use in emergencies: aradiologist does not physically haveto be where the examination takesplace, but someone who specialisesin radiation protection does - a doc-tor who can supervise examinationsusing contrast media, for example,and who can help if there are prob-lems, such as allergic reactions, etc.’
After receiving images on the lap-top, a diagnosis is made and thepatient’s name and results areentered under the radiologist’s letter-head. Within minutes, that report isthen automatically transmitted to thehospital/referring doctor, again viathe laptop.
Laptop criteria - Arpad Bischof,who developed Morits at the UK-based company Image InformationSystems Ltd, explained: ‘You need atwo mega-pixel display with highcontrast, homogenous light field andhigh light density. We have a diagno-sis module based on a high-end
he added. ‘We comply with DIN-Norm 6868-57 for medical diagnostic imaging with CTand MRI, but not with the regulations onimage diagnostics for conventional diagnos-tics. You can use the system for a secondopinion in conventional diagnosis or forultrasound scans as well. However, we donot recommend using it for a primary diag-nosis.
‘Data protection is another importantissue,’ he pointed out. ‘We offer two pro-
cedures. All data leaving the hospital isencoded, and the hospital’s system isprotected via a firewall againstpotential intrusion from the inter-net, using the most modern tech-nology available. This is vital.Additionally, we have developed anoptional pseudonym procedure, so
that images are not transmitted withactual names, but with identificationcodes. It’s very similar to the way labora-tories encode blood samples.’
Although the system may sound com-plex and expensive, Arpad Bischof point-ed out that it costs less than 20,000 eurosand transmission costs are under 50cents per examination, and added thisassurance: ‘There’s a big savings potentialfor all specialist clinics and hospitals thatoffer night cover and emergency medicalcover.’ Details: [email protected]
Gemeinschaftspraxis für
Diagnostische Radiologie, 47906
Kempen, Mülhauser Str. 32, Germany.
Image Information System Ltd, 483
Green Lanes, London, N13 4BS, UK
Mobile radiology diagnosesThe new radiologist: ‘Always online’
8
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square metres.EMM handles all aspects of the pur-
chasing process, from testing and de-installation to a safe and professionalremoval from a hospital site anywhere inthe world. ‘All the hospital has to do ismake the purchasing agreement, decidea de-installation date - and make sure thesystem is not scheduled to operate on theday of the pick up!’ said Lars Nielson. ‘Ourmain partners and suppliers are locatedin Western Europe and America, whilstour customers and end-users come fromdeveloping countries as well as manyEuropean and other developed countries.Many hospitals maintain a strong focuson costs and find in financially wise topurchase high-end second user equip-ment from us, because we can offeralmost new scanners with very littleusage and some of the newest applica-tion options. In developing countries it ismore important simply to get access toequipment. Even older equipment oftenmeans that many lives can be saved.’Details: www.epokamedic.com
EH-ECR 1/05
And finally ... PACS protects against diseaseHong Kong - A PACS network became a useful ‘barrier’ to protect medical staff duringthe recent outbreak of the highly infectious severe acute respiratory syndrome(SARS).
When treating 70 SARS patients at the Tseung Kwan O Hospital (TKOH), Hong Kong(where a PACS was installed in 1999) no film was printed, except when any patienthad to be transferred to another hospital. Imaging equipment was set up in the ICUand a SARS clinic. Only 1% of the SARS patients needed an X-ray follow-up - and X-rayimage viewing, via the electronic network, was sufficient for radiological diagnosis.
The hospital’s PACS has a storage capacity of about 5 TB (inc. 2.3-TB storage-areanetwork set-up). Performed on the SAN, the DICOM compression rate is 2.5. The net-work has a cluster of automatic fail-over switches. Using a cluster of three Webservers for image distribution, image-viewing systems are set up in wards usingembedded LCDs, wall-mounted computers, barcode scanners, and smart-cards. Amobile image-viewing trolley is also available during procedures.
Reporting at the RSNA in November, Dr Carrison Tong, of the hospital’s medicalphysics department, said that this system had contributed to the continuous monitor-ing of patients’ responses to drugs, and that none of the radiology department staffhad been infected during the outbreak. ‘Filmless radiology services provided an impor-tant tool for the care of SARS patients - and the protection of healthcare workers,’ heconcluded.
EH@ECR 2005 was produced by EUROPEAN HOSPITAL, the leading bi-monthly pan-European healthcarejournal. Other publications include the @MEDICA series, in tandem with the international medical tradefair, and DESIGN in EH, which focuses on hospital architecture/interiors as well as advanced designs inmedical equipment. Contact details: www.europeanhospital.com or ECR supplement p 19
Denmark - The Epoka Medic Mission A/S(EMM), based in Pandrup, re-utilisesexisting medical technology resources byoffering pre-owned equipment at competi-tive prices to customers in over 80 coun-tries. ‘One of the main reasons for oursuccess is our ability to make quick buy-ing decisions and take immediate action,’explained the firm’s CEO Lars BraunNielsen (right). ‘Many of our most impor-tant suppliers are important decisionmakers in the hospital world. When ourpartners wish to sell their old equipmentthey’ve already ordered the installation ofa newer generation, which means wemust be flexible and be able to deliver theright timing and technical expertise forde-installation and pick-up from the cus-tomer site.’
He co-founded EMM, in 2003, with theowners of the Epoka Group A/S, whichhas been an international reseller of pre-owned, refurbished, high-performance ITequipment since 1991, and could pass onconsiderable experience and knowledgeto the new firm. Today, EMM employs 10
people forpurchasing,sales, techni-cal supportfor de-instal-lation andinstallation,shipping andl o g i s t i c s .Additionally,within thelast six months the sales force hasexpanded by four people.
The firm’s strong financial position(with a 2004 turnover of 40 millioneuros, Epoka Group A/S has a triple Arating from Dun & Bradstreet) means itcan buy high-end equipment for inventoryand speculation purposes, such asdevices made by leaders in CT, MRI, X-ray, Ultrasound Scanners, Angio & CathLabs, Mammography and PET/NuclearSystems, buying and selling all brandsand generations between 1992 and2005. For storage the firm has one ofEurope’s biggest warehouses: 3,000
IT managers inevitably invest insecurity, such as firewalls, but manyignore aspects of physical security byleaving data unprotected from itsimmediate environment: servers, net-work components and other hard-ware systems may be located next tocopiers, or even kept in rooms whereeasily combustible materials arestored. Apart from fire itself, corro-sive combustion gases can constitutea primary risk, as can unauthorisedaccess, dust and electromagneticradiation.
At a Zurich hospital, LampertzGmbH, which custom-builds IT pro-tection units, has installed a modularIT security room to physically pro-tect data and systems. This ‘roomwithin a room’ (recently ECB•S cer-tified) contains ‘...individual fireproofconstruction elements linked togeth-er in a water and gas proof way,’ thefirm explains. ‘The security cell canthus be flexibly set up, taken apart,extended or moved, and imposespractically no requirements on thestructure of the building itself. Ifspace requirements change, theroom can be easily adapted ormoved. Apart from flexibility, thissolution meets all security require-ments for systems locations, throughEuronorm EN 1047-2 for data securi-ty containers and rooms.’
Lampertz emphasises that it makessense to divide up a central IT areainto different sections, for which dif-ferent security requirements mightapply. ‘Finally, there are other securi-ty requirements for mission criticaldata and systems, for example com-ponents designed for redundancy,such as a parallel IT system. It istherefore more cost effective if the
Germany - The healthcare sector islooking to cut costs through increasedinvestments in information and com-munication technology and its strin-gent use. According to a recent poll bySteria-Mummert Consulting, inHamburg, in 2003, German hospitalsspent around 12% of their total bud-gets in this area, and in 2004 that fig-ure rose to 18%. Spending by compul-sory medical insurers rose from 13%to 20%, private insurers increasedtheir spending in IT from 14% to 35%.To achieve even more efficiency, 60%of hospitals are looking at invest-ments in treatment processes, whichare to be tightened through the DRGs,and into electronic purchasing (e-pro-curement). 72% of all insurers foreseea big savings potential in automatingthe processing of claims, and 79% ofthe compulsory insurers are planningto invest in e-health by 2006, with55% of the private insurers also look-ing at this kind of investment.
The Federal Association forInformation Management, Telecom-munication and New Media (BITKOM)estimates savings of up to €1.3 billionthrough the introduction of the elec-tronic health card. An exhibition ofsolutions for those cost-saving objec-tives will be held at the ITK trade fair,CeBIT. 10-16 March, in Hanover.
IT room solution can also incorporatea corresponding layered approachwhen it comes to security.’ The firm’sDataCenter is a modular security sys-tem. ‘This scaleable and thus individ-ually selectable, made-to-measure ITsecurity solution offers three furtheradvantages over and above extensiveprotection: as a system it can be certi-fied, and is therefore of interest toinsurers,’ the firm points out, addingthat the modular construction methodalso provides more advantageousdepreciation treatment. Finally, thecomplete room system can befinanced. ‘This allows lines of creditto be used more sparingly,’ Lampertzsays. ‘So the work does not impactthe balance sheet.’Details: www.lampertz.de or:[email protected]
Growing trades: buying and selling used imaging equipment
As electronic patient’s records (EPR) - complete withirreplaceable radiological and surgical images - increase in size,numbers and importance, why are some managers lackadaisicalabout their protection? A room with
a view to
SECURITY
Procurement
Cost cutting via IT
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New arrivals on the healthcare platform face a welcome - and controversy
continued on page 2
10-11Surgery
Centralised OT
control, tissue
engineering,
lighting,
clothing
T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K
ECR
SupplementCentre pull-
out section:
radiology, IT and
administration
20 pages
EUROPEAN HOSPITAL
‘Clandestine mercy killings of neonates must end’
ECR PULL OUT
Page 1-16
continued on page 2
Possible SCP procedures include:
● Breast biopsy ● hernia repair
● vasectomies ● testicular torsion
● small bowel anastamoses
● opening/closing for laparotomy
● fracture manipulations
● open fracture debridement
● arthroscopies and ACL
reconstructions
● shoulder stabilisations
● reduction and fixation of facial
bone fractures
Waiting lists, EU limits on working
hours, doctor and nursing staff short-
ages, how could healthcare providers
overcome all those hurdles let alone
glimpse the winning post ahead? A
scheme launched in the UK may pro-
vide some answers by shrinking lists,
easing working hours, as well as
attracting more people to enter the
nursing profession.
As part of the UK Government’s
revolutionary plans for the country’s
National Health Service (NHS), nurs-
es are now being trained to perform
a range of surgical procedures.
The length of the training is two
years, and those who qualify will be
called ‘surgical care practitioners’
(SCP). Up to 5,000 nurses, physio-
therapists, and operating theatre
assistants are expected to become
SCPs within 10 years, and the pay
scale proposed for three grades of
SCPs is expected to be €50,766 euros
per annum.
Behind this job revolution is The
NHS Modernisation Agency’s ‘New
Ways of Working Programme’.
Explaining this concept, an agency
spokesperson said that the NHS is
trying to give its staff greater job
opportunities, and that job upgrades
are about ensuring that people who
have the potential and skills are
being used effectively. Indeed, the
NHS has already upgraded the role
of certain radiographers, as well as
nurses in terms of their being
allowed to prescribe certain medi-
Report byBrenda Marsh
cines. In addition, without formal
training, an estimated 400 NHS
nurses already perform procedures
such as vein stripping from the leg
for coronary bypass surgery, and
some procedures in orthopaedics,
ophthalmology and gynaecology.
Another significant point made by
the NHS Modernisation Agency is
that the use of SCPs in two hospitals,
reduced the average time for bilateral
varicose vein surgery by 30 minutes
in one and in the other enabled a
two-week target for bladder cancer
treatment to be met.
However, as some twenty-five pilot
schemes for this training in ‘simple
operations’ continued, the further
The Netherlands - Although this
country became the first, in 2002,
to legalise euthanasia for people
aged 16 years and over, child
euthanasia remains illegal.
Nonetheless, 72% of Dutch doctors
are in favour of this in extreme
cases, and a survey has suggested
that the lives of about 15-20 dis-
abled neonates are ended annually
there. However, the first Dutch
study to focus on child euthanasia
has demonstrated that physicians
are so afraid of criminal prosecu-
tion that, since 1997, only 22
deaths involving terminally ill
babies were reported. ‘It’s time to
be honest about the unbearable suf-
fering endured by newborns with
no hope of a future,’ said one of
the study’s authors, paediatrician
Eduard Verhagen, of Groningen
University Medical Centre. Out of
compassion, he added, doctors
everywhere end lives discretely and
without any regulation.
‘Worldwide, the US included, many
deaths among newborns are based
on end of life decisions, after physi-
cians reached the conclusion that
Euthanasia debate rekindled
there was no quality of life. This is
happening more and more frequent-
ly. If we take this awfully difficult
decision, it must happen with com-
plete openness.’
The study, conducted with the
cooperation of the Universitair
Medisch Centrum Groningen, and
published in Nederlands Tijdschrift
voor Geneeskunde (www.ntvg.nl),
aims to highlight under-reporting
and to encourage doctors to report
cases without fear of prosecution.
The authors point out that none of
the physicians involved in mercy
killings was prosecuted. In the cases,
involving babies with extreme spina
bifida, it was revealed that four
unofficial rules were used to guide
prosecutors in their decisions not to
charge those involved in these
deaths. The criteria: the child’s med-
ical team and independent doctors
had agreed; the child’s condition
could not be improved, nor pain be
eased; the parents had consented
and the life had ended in a medical-
ly correct manner.
With the agreement of Dutch legal
SARS no longer deadly
threat - But avian flu is
USA - Scientists are confident that the
virus that caused severe acute respira-
tory syndrome (SARS) is no longer cir-
culating in humans, or other animals,
according to Professor Kathryn
Holmes, a microbiology expert at the
University of Colorado, USA. Only if
the SARS virus could evolve again - as
an identical mutation of the original
animal coronavirus - or if it were acci-
dentally released from a lab - could it
become a threat again, she said at a
recent meeting of the American
Association for the Advancement of
Science.
Indeed, after the epidemic, the
virus escaped, three times, from
research centres in Taiwan, Beijing
and Singapore. However, just nine
people were infected and the elderly
mother of an infected Chinese lab
assistant died. Now, even if such an
accident or mutation should occur,
Prof. Holmes said, there several SARS
vaccines and treatments to block
infection, and the quarantine meth-
ods are better understood.
Avian ‘flu - Nancy Cox, chief influen-
za scientist at the US Centres for
Disease Control, has called the threat
from the avian influenza virus - which
has killed 42 people in Asia - ‘very
frightening’. Its death rate is now
76% - compared with 1% for the
Spanish flu that killed about 40 mil-
lion people in 1918-19.
FREE INSIDEECR SUPPLEMENT
Funds for adults with
hospitalised children
Germany - The Federal Associations of
Health Insurance Funds and the
German Hospitals Association are now
following Germany’s Regulation 1 on
the co-admission of child/adolescent
patients and accompanying adults.
From January this year, a universal
rate of 45 euros a day has been allo-
cated to cover extra accommodation
and food for an accompanying par-
ent, or family member or someone
chosen by those with parental respon-
sibility for the child.
‘This has finally put one of the stip-
ulations of the Charter for Children in
Hospital (agreed in 1988) into prac-
tice, said Jochen Scheel, who heads
the board of the Association of
Children’s Hospitals and Children’s
Wards in Germany (GKinD). The co-
admission of an accompanying adult
in Children’s Hospitals is known to
have positive effects on recovery, he
said, so co-admission of an adult can
always be medically justified, apart
from certain admissions to paediatric
psychiatric wards, or for some children
with psychosomatic symptoms. ‘From
our experience gained in children’s
hospitals we know that the co-admis-
sion of an adult is also dependent on
the state of development of each indi-
vidual child and of the characteristics
and severity of the illness. Up until
now the admission of accompanying
adults was not governed under a
nationwide scheme but was handled
on an individual basis, dependent on
the medical insurer and location of
the hospital. There rarely were any
sensible or suitable solutions; in fact,
things were often quite confusing and
rather arbitrary. Now there’s an end
to all that!’
Signature Date
Please inform me about the Hospital AdministratorForum at the ECR 2006.
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A D M I N I S T R AT O R S F O R U M
“It is my great pleasure to welcome you to this meeting today - I did not
say ‘annual’ meeting because it is too early to promote it as such. For the
time being, this is simply an occasion to gather together administrators
who are participating in ECR 2005, so that you can exchange ideas and
opinions. However, the broader idea is that this meeting will mark the
beginning of an annual tradition that will include discussions on
high-technology and its financing.
The time has already arrived when hospitals no longer rely
solely on doctors - an opinion doctors also share, for they
understand that a modern hospital is defined not only by its
highly professional medical teams, but also by leading-edge
equipment, informatics applications and innovative
programmes. Administrators play a key role in this
changing world, where progressively reduced
resources are met with rising costs. With an
increasingly aged and abundant population, such
obstacles present a hefty challenge.
Evidently, these problems, just like healthcare systems themselves, vary from
one European country to the next, so that hospital management in London is
different from that of Munich, Prague, or Moscow. In all cases, patient-
oriented hospital management remains of utmost importance, and marketing
and sales strategies play new roles for promoting financial support for
hospitals.
Application Services Providers (ASP), project financing and
benchmarking, are some of the words that administrators
increasingly use. This meeting is the ideal place where these ideas
can be shared by administrators of different origins and who work in
different environments, so that they can work towards a more
uniform European standard of healthcare.
Looking into the future, I would like the 2006 administrators
meeting to be hosted in the main building at the Austria
Centre, and that it will not end next year, but establish
itself as an annual meeting.”
Professor Antonio Chiesa, ECR Congress President, welcomes visitors to the Hospital Administrators Symposium
In European countriesthe in-patient lengthof stay has decreasedconsiderably.Consequently, from1990 to 2001 the num-ber of hospital bedsshrank by 19%although 20% morepatients were treated.
This efficiency increase could be realised -not entirely but to a great extent - due tomodern imaging diagnostics and minimallyinvasive radiological procedures. Fast andprecise diagnostics, which puts little stresson a patient, enables us to start an effectiveand targeted therapy briefly after thepatient has been admitted to hospital. Inthese diagnostic procedures radiologicalequipment such as CT and MRI play a cru-cial role.
Often, medical technology is held respon-sible for the explosion of costs in healthcare.However, the facts tell a different story: InGermany (for example) major medical tech-nology equipment accounts for only 1% ofannual health expenditures and only 0.2% isspent on investments.
These facts notwithstanding, re-invest-ment and modernisation have become evermore difficult. In Germany, over 50% of theradiological equipment in use is more than10 years old, which means it is outdated,requires high-maintenance and thus, in theend, it is no longer economical. Even healthpoliticians understand that 10 to 12.5 billioneuros need to be earmarked for investmentsin healthcare annually, but only five billioneuros are available. As a result, during thelast years, an investment backlog of 25-35billion euros has accumulated.
This development is, at least in Germany,a direct consequence of the structure of thepublic healthcare system. Public budgets are
Innovations:between hi-tech andeconomic viability
By Professor Maximilian F Reiser, directorof the Institute of Clinical Radiology at the
University Clinic, Munich, Germany
in dire straits, which makes urgently neededre-investments impossible - notwithstandingthe fact that, as has been proved, innovativemedical technology contributes significantlyto cost reductions and quality improvement.
It has to be taken into consideration thatwe are currently witnessing a change of par-adigm within radiology which may well leadto a further efficiency boost - for example viawhole-body imaging with state-of-the-artMRI systems, PET/CT and multislice CT.Instead of a sequence of diagnostic steps, theentire body is scanned in one go, which fur-ther avoids delays. Moreover, interventionalradiological procedures, such as radio fre-quency ablation and vertebroplasty, are high-ly effective and help reduce treatment costs.
But how can we realize these cost-efficientand doubtlessly useful innovations in a situa-tion characterised by scarce resources? It isnot enough for the radiologists to makedemands and then complain if thosedemands are not met. Rather, we must makeevery effort to reduce operating costs byimproving organisation and workflow. Newfinancing models must be developed by part-nerships between hospital administrationand industry - however, such public-privatepartnerships require mutual trust.Particularly promising seems to be a ‘Pay peruse’ model, which allows a hospital to avoidhigh initial investments but at the same timeguarantees long-term budgeting, and is inte-grated into a strategic investment plan.Hospital and industry partners share risks, aswell as profit, and both partners have a vest-ed interest in the economic success of theproject.
Radiologists and hospital managers shouldmake every effort to convince financial deci-sion makers that investment in medical tech-nology and in IT infrastructure can improvethe quality of healthcare and at the sametime reduce costs. The one-sided orientationand support for pharmaceutical research anddevelopment has long been proven as anexpensive error.
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A D M I N I S T R AT O R S F O R U M
Volker Hüsken PhD: Following his PhD studies in information technologyand economics, in the department of electrical engineering at the RWTHAachen, Dr Hüsken became a systems engineer at Siemens AG, where hedirected the development of the Super Computer Reference Centre. After several years as IT Director with Klöckner Datentechnik and EDS, hebecame Senior Consultant for strategic acquisitionswith EDS, and was then asked, by the GermanArmed Forces, to design its intranet.Later, Dr Hüsken, as Managing Director ofinternational Sema Group, he was responsiblefor its ‘Civilian IT’ and ‘Consulting’ divisions,which focused on business development incommerce, banking and utilities. Dr Hüsken became IT Director and CIO of theUniversity Hospital of Cologne in 2003 and,in 2004, Managing Director ofMedUniServ GmbH, a serviceprovider owned by the universityhospital
Dr Volker Hüsken describes cost-efficient and patient-orientedhospital management in a major German clinical complex
If the new requirements for majorchanges in the billing and docu-mentation of hospital services areto be fulfilled, whilst still reaching
priority objectives (cost-efficiencyand patient-orientation) the futureIT infrastructure must be developedin a far more strategic way. The tra-ditional approach, with its multitudeof department-based systems andapplications, is no longer viable. TheIT department has to support thenew financial and organisationalfreedom accorded to the hospital bythe new legal framework efficientlyand quickly - particularly organisa-tional changes by sustaining ‘makeor buy’ decisions.
Today, a hospital no longer definesitself by its traditional hospital activi-ties but as a healthcare company, i.e.a service provider in the health mar-ket. Consequently, medical leader-ship must define, as clearly as possi-ble, the main medical foci, includingall peripheral parameters. That strat-egy serves as a guideline for thedevelopment of the IT infrastruc-ture. Keeping the broadest possiblerange of services and equipment instock and striving for utmost flexibil-ity is neither cost-efficient norpatient-oriented.
For IT, the development of ahealthcare company means thatworkflows must be established inde-pendently of the organisationalframework, so that internal or exter-nal resources can provide services.This particularly concerns medicalservice providers in the areas of lab-oratory, radiology, nuclear medicineand radiation therapy. Concepts for ahospital electronic patient’s record(EPR) not only have to take intoaccount the entire patient recorddocumentation, but also, and aboveall they have to cover the completeprocess behind a medical service,from requests for diagnostics totherapy. If the IT infrastructurecauses interruptions or gaps in theimplementation of such a concept orworkflow, the medical and manage-ment information value of storeddata becomes distorted. Only a uni-fied and integrated system will allowa meaningful assessment of the realquality and performance of healthservices.
An IT strategy must first deter-mine which system will be responsi-ble for all transactions involvingaccounts and which one will dealwith the patient’s medical data.Then, specific services, such as com-munication, archiving and the man-agement information system, mustbe considered. All these serviceshave to be accessible from all appli-cations, and must allow for externalcommunication.
The final strategic decision con-cerns the choice of a laboratory sys-
tem, where the focus is on efficientautomation of all laboratory proce-dures, rather than on patient-orient-ed services.
The question of how pathologyservices are to be integrated into asystem is still under discussion. Thecross-sectional approach to commu-nication, co-operation and informa-tion processing and display is thelast of the cornerstones of a hospitalto be built on internet technology. Itis particularly important that all sys-tems follow a common standard,which means not only communica-tion standards for data exchange butalso standards with regard to userinterfaces, the integration into anoperating system and a databaseenvironment and user administra-tion. These standards notwithstand-ing, any integrated system must pro-vide a certain degree of freedom toaccommodate individual needs.
In this context, the role of theapplications vendor needs to be re-evaluated. The software-vendingfirm must be included in a hospital’sstrategic business planning, so it canunderstand future requirements andprepare itself accordingly. Obviously,the traditional department-basedvendor policy is obsolete. The hospi-tal as a whole enters into a long-termco-operation with a vendor - a factthat both parties should be aware of,because that is the precondition forthe speedy implementation of soft-ware decisions and requests - a cru-cial capability in today’s fast-chang-ing market. For example, the KISvendor has to explore today how, inthe future, individual contracts withpatients can be reflected by theapplication. Consequently, price canno longer be the exclusive determin-ing factor for software purchase.Professional trust and confidenceand co-operation are the basis ofbusiness dealings - and obviouslythat is something that can be devel-oped with five but not 50 providers.
The transition from a decen-tralised to a centralised IT depart-ment also always has profound impli-cations for the users. The user isinterested - understandably so - inhaving a quick response and all con-ceivable support from the IT depart-ment, whenever it is needed, and herarely understands the demands of asuperordinated process. For theuser, centralisation means that he nolonger has direct access to ‘his’ ITsupport person next door, but thatthis colleague is part of a largerstructure and that, most likely, hehas no power to set priorities. Oneapproach to avoid frustrations is theimplementation of a system of ser-vice levels and, for the user, this hasto be transparent and make theactivities of the IT department pre-dictable. A system of service levels
according to ITIL is quite commontoday. It is crucial that management,and the board, support such a con-cept - otherwise every attempt toimplement standards, be it for appli-cations, hardware or services by theIT department, is doomed to fail.This certainly also holds true formedical technology used in a hospi-tal.
Very often, the IT staff must ‘takethe rap’ for many of the daily deci-sions regarding organisation andworkflow necessitated by IT pro-jects, and IT staff must be aware ofthis fact of life and realise that it isquite useless to fight that. Instead,IT management has to make sure itsIT staff has the qualities and qualifi-cations of consultants, because thatis what they are: they act as consul-tants to the hospital because they
How to sellyour hospitalJörg F Debatin MD MBA, Medical Director andCEO of the University Medical Centre, HamburgEppendorf, outlines strategies for administratorstaking on a relatively new role - in marketing
To date, healthcare throughoutEurope has remained largelyinsulated from normal marketmechanisms. Rather, healthcare
providers are operating in a jungle ofrules and regulations created bybureaucrats and enacted by politi-cians. Obviously, there are many rea-sons why healthcare cannot be con-sidered a ‘normal’ market. First andforemost, health is a very specialcommodity, which should be afford-able for all members of a societyregardless of their income levels.Acceptance of this paradigm remainsthe basis for all European healthcaresystems. Despite the introduction ofpatient co-payments for physicianvisits, as well as medication, thankful-ly there appears to be consensus thathealthcare needs to remain availablefor all in need.
Insulation from market mecha-nisms has resulted in highly ineffi-cient healthcare service structures.
Ever increasing healthcare costs havenow resulted in a growing trendtowards the introduction of marketmechanisms based on supply anddemand. In some regions, particular-ly large metropolitan areas, health-care providers are therefore con-fronted with increasing competitionmandating the development of mar-keting and sales strategies for individ-ual healthcare providers. Points to take onboard: ● Current health systems based on
state-governed regulations havefailed to provide affordable andefficient healthcare.
● The introduction of market mecha-nisms based on supply and demandto healthcare is rapidly gainingacceptance.
Healthcare: a special productIn an abstract sense healthcare is aproduct rather different from mostother commodities. From a customer
have the knowledge of almost allactivities within the hospital. Today,in most organisations, only very fewstaff members could fit that bill - notsurprising considering the history ofIT and IT hospital departments.
The questions of who is responsi-ble for the fulfilment of the variousdocumentation requirements is amajor issue today - and it is an issuewhich increasingly impedes theimplementation of IT projects sincethere are ever more parameters thathave to be included to be able toevaluate services and quality. Weknow from other disciplines thatdocumentation assistants are a verygood solution to free medical staff toconcentrate on their core task ofproviding medical services.In short, cost-efficiency and patient-orientation mean:
● general systematics to implementelectronic patient records areavailable
● limitation to a few strategicapplications
● integration beats specialisation● central standards for
hardware/software ● paper-based processes are
discontinued● fast fulfilment of all documentation
requirements ● flexible applications with room for
individual needs ● intuitive and standardised user
interface ● meaningful data analysis that does not
allow for individual interpretations● implementation of service levels ● professional trust in and co-operation
with vendors ● location-independent services.
perspective it is of unsurpassed value,as it represents the virtual bases for aproductive life. Despite its importanceto the individual patient, it is difficultfor the customer, i.e. the patient, todefine its monetary value or therequired product quality. Healthcareproviders expect their patients totrust that their product is of high qual-ity and priced correctly. In view of themultitude of regulations governing theway healthcare is provided, patientsonly too willingly place this trust intohealthcare providers and their profes-sionals including physicians, nursesand technologists.
Unfortunately, the reliance on rulesand regulations to assure sufficientquality of healthcare is not really war-ranted. In contrast to all other prod-ucts, regulations governing the healthsector only affect the process ofadministrating healthcare regardlessof outcome. If the same principleswere applied to the production of cars,
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A D M I N I S T R AT O R S F O R U M
the assembly of brakes in a car wouldbe regulated, whereas performance ofthe same brakes would not be subjectto any checks at all. Increasinglypatients are becoming aware of thiscentral shortcoming of Europeanhealthcare systems. Pressure hasgrown to a point where even govern-ments are reacting. New rules andregulations are being implemented.Most again fall short of what is need-ed: transparency of quality and pric-ing for healthcare products to the cus-tomer, i.e. the patient. Hence, effortsto provide reliable quality data can beconsidered one of the most importantcontributions to any health marketingstrategy.
The process of pricing healthcareproducts has remained as elusive tothe average patient as the assessmentof product quality. For many health-care services patients do not evenreceive a bill. Rather, payments areprovided by anonymous insurance orhealth service agencies, in accordancewith rules lacking in transparency -and frequently sense. For the health-care market to gain in efficiency, it isof utmost importance that pricingbecomes transparent to the patient.Clearly this does not mean that invoic-es also should be paid directly by thepatient. Rather, the underlying insur-ance system with acceptable co-pay-ments should be maintained.Points to take onboard: ● For market mechanisms to unfold
their desirable effects, healthcareproducts must become far moretransparent to the customer, i.e.patient, regarding pricing and qual-ity. The latter should be based onoutcome and should represent acentral theme in all marketingstrategies.
● While transparency in pricingrequires patients to be billed, itdoes not require the patient to paythose bills themselves. Rather, theunderlying risk sharing systemsshould be maintained as payers.
Hospital marketing strategyMost healthcare professionals wouldprobably associate marketing withadvertisement strategies. First andforemost, such strategies should focuson information to the patient.Transparency should be providedregarding the quality of the medicalproducts offered. The creation of anattractive and content-rich internetplatform clearly represents a cornerstone in this undertaking.Furthermore, occasional press releas-es that document the success of med-ical treatments should be preparedand distributed into all available chan-nels. Finally, advertisement strategiescan also include direct marketingmeasures, such as letters to treatedpatients outlining progress in diagno-sis and therapy regarding their dis-ease. The healthcare provider shouldbe careful however to respect all lawsand regulations governing advertise-ment in the healthcare sector in mostEuropean countries.
Marketing however covers far moreground than mere ‘advertisement’. Ina sense marketing represents the verycore of any company by first and fore-most defining a product portfolio. Hence we can summarise as follows:The central aspect of any marketingconcept relates to the definition ofproducts Advertisement strategies onlyrepresent the tail end of a marketingconcept.
Product portfolioIn our current hospital world productportfolios, by and large, have devel-
oped in a historic sense. While thereare variations in the number and typeof healthcare products offered by dif-ferent hospitals, few providers haveconsciously decided upon what isoffered as part of the existent prod-uct portfolio. Rather, portfoliosappear to be the results of historicprocesses based on individual physi-cians interests and abilities as well asperceived patient needs, expressedby insurance carriers. Frequently, ahospital offers various healthcareproducts for no identifiable reason atall.
As a first step in the process ofdeveloping any marketing strategy,
the currently offered products shouldbe listed. Using portfolio analysistools, each of these products shouldbe analysed in terms of quality, prof-itability, and future relevance. Theassessment of quality and profitabili-ty should be based on comparativebenchmarking data. Both factors gen-erally relate to volume. Thus, there isample data to illustrate a direct rela-tionship between outcome quality ofa particular procedure, or operation,and the number of times that the pro-cedure is performed within the samehospital in a given time frame. Casevolume has also emerged as a directpredictor for cost. Similar to most
other products, economy-of-scaleeffects also contribute towardsreduced cost of medical procedures.Put differently: the same procedurebecomes less expensive if it is per-formed more often within the samehospital. Points to take onboard:● Product Portfolios should be con-
sciously defined based on differentcriteria including quality, cost and‘future relevance’.
Unique selling Proposals (USPs)Future relevance of products relatesto existent Unique Selling Proposals(USPs) of the hospital offering the
product. Each hospital should definethese USPs, which set it apart from itsmost direct competitors. USPs canrelate directly to the type of patientgroup served by the hospital (commu-nity hospital vs. specialised referralcentre), medical services on offer (car-diac surgery, organ transplants), or thequality of care provided. In addition tothis, USPs can also relate to aspects ofprocess affecting all products, such as aspecial means of nursing, the imple-mentation of a quality assurance pro-gramme or a particularly innovativemeans of electronically archiving med-ical patient data. continued on page 12
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A D M I N I S T R AT O R S F O R U M
The advent of a digital networkfor picture archiving andcommunication systems(PACS) reduces all the steps in
retrieval and archiving of images andprevious diagnoses to minutes - oreven seconds - and links the relevantdiagnostic and other departments.PACS connects all modalities (CT,US, MRI, plain film, etc) to a centralcomputer, which for security reasonsstores the image data redundantly.
To leverage such a system’s manyadvantages, a PACS of appropriatesize and scope must be chosen.Experience has shown that state-of-the-art equipment, such as a multi-slice CT scanner, can overtax aPACS that was not designed toaccommodate it. Consequently, theworkflow slows considerably, if notunacceptably. Therefore, beforechoosing a PACS, long-termplanning, which includes theidentification of all current andfuture devices to be integrated withthe system, as well as the data
USPs should be designed to be asdefensible as possible. Thus, USPsthat can be easily copied by a com-petitor are of considerably less valuethan those that will remain trulyunique - preferably over a very longperiod of time. Put differently: UniqueSelling Proposals should be associatedwith ‘high barriers of entry’ for anypotential competitor. For a University Medical Centre, thefollowing USPs seem relevant:All products requiring aninterdisciplinary approach
Because university hospitals willgenerally be home to more sub-spe-cialists than other hospitals, diseasesthat require a multi-disciplinaryapproach will be treated in a more effi-cient manner.Complex diseases requiringintensive careBecause university hospitals are gen-erally equipped with vast intensivecare resources, they should be used totreat the most complex disease enti-
ties that require such services.
Ability to adapt to new therapiesBecause university hospitals encom-pass research, as well as medical care,it should be far easier to implementnew medical advances in healthcareproducts.
Once defined, USPs should bechecked against those products thathave been determined as being of highquality as well as high profitability. Inthe end, only those products that com-bine defensible USPs with high med-ical quality and profitability should befurther developed and entered into afuture product portfolio. Points to take onboard:● USPs can relate to various aspects
defining the character, infrastruc-ture or medical abilities of a hospital
● Defensible USPs are those associat-ed with high barriers of entry forany direct competitor.
Sales strategiesOnce a product portfolio has beendefined, the hospital infrastructurehas to be developed in a manner tostrengthen the ability to deliver theseproducts at maximal quality in mini-mal cost. These efforts should bemade transparent to the customer bypublishing them on the web.Furthermore, these efforts must pro-vide the bases for any direct salesstrategy that, in common with all otherindustries, can only be based on quali-ty and pricing. In this regard it will bemost important to provide transparen-cy regarding the definition of quality.Clearly, these aspects will need to beregulated in a homogeneous, hopefullyEuropean manner. Points to take onboard:● Any sales strategy must be based on
transparency regarding the qualityand pricing of the medical productsoffered.
● Attention must be paid to existinglaws and regulations governing thehealthcare sector.
SummaryHealthcare is rapidly evolving from atotally non-transparent and heavilyprocess-regulated system to a compet-itive market. To survive in such a mar-ket, hospitals will require the con-scious development of marketing andsales strategies. These should bebased on a product portfolio definedby quality, profitability and UniqueSelling Proposals. The basis of market-ing and sales strategies must howeverlie in providing transparency to thecustomer, i.e. patient, regarding out-come quality and pricing of healthcareproducts.
COLLABORATION BETWEENIMAGING FACILITIES Peter Bogner MD PhD describes current projects aimed atenhancing patient care in South-West Hungary
Professor Peter Bogner MD PhD med. Habil. Is vice-director of the Institute ofDiagnostic Imaging and Radiation Oncology, University of Kaposvár, Hungary and healso works in the Dept. of Radiology, at the Health Science Faculty, University ofPécs. In his early career he was a post-doctoral fellow at Hungary’s NationalAcademy of Sciences, and at the Dept. of Clinical Chemistry, University MedicalSchool of Pécs, as well as in the dept. of Biochemistry and Molecular Biology,Medical School of Ohio, Toledo, USA. Later he was Fogarty fellow at the Laboratoryof Biological Chemistry, National Institutes of Health, National Cancer Institute,Bethesda, USA (1989-91). On returning to Hungary he worked in an institute thatbecame the Institute of Diagnostic Imaging and Radiation Oncology. Researchcontinued at the Department of Clinical Chemistry, University Medical School ofPécs. In the years 1997/98 and 2000 he was also a visiting research radiologyfellow at the Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.Current research interest: cell volume regulation, diffusion MR imagingThe Professor’s scientific publications and honours are too numerous to list
Diagnostic imaging informationplays an increasingly significant rolein healthcare, primarily due toadvanced imaging techniques. Inaddition, recent developments ininformation technology add majoradvantages that can improve the useof diagnostic imaging information aswell as the medical and financial effi-ciency of imaging procedures. Infact, recent IT solutions offer a safeand flexible access to digital imagesin a wide area network that iscurrently developed and/or usedglobally.
Along with becoming a member ofEU, in Hungary the reorganisation ofpublic administration has begun.This means that the former threecounties of South-West Hungary willjoin to form one region among thefive that will represent Hungary inthe future. This process seems toevolve somewhat slowly, but EUfinancing helps to establish differentorganisations that will functionaccording to this concept in the nearfuture. One such example is thedevelopment of a medical IT systemin South-West Hungary that will beshared by nine institutes of differentsize and competence. There is, ofcourse, a hierarchical organisation ofhealthcare in the region, where theclinical departments of a medicalschool would represent the highestprofessional level followed by threecounty hospitals and several out-patient services. The principle aim ofthe regional medical network to bedeveloped is the sharing and easycommunication of medical informa-tion, gained through the diagnosticand therapeutic procedures in whicha patient has been involved at certaininstitutions. No doubt that imaginginformation is the most demanding,especially in terms of its size andproper visualisation.
There have been two main trendsfor storing and sharing diagnosticimages in a wide area network: ● to maintain large central (in our
case possibly regional) archivingfacilities that can be accessed byeach institute
● local archiving that is maintainedby each institute and shared datathrough some kind of data broker.
Large central image archiving facili-ties appeared to have several advan-tages, like bulk storage rates; opera-tion by a dedicated professional stafffor data management and for hard-ware support and high level of physi-cal security. This concept involvedeasier technological migration,which is a major issue for any localIT staff. Since healthcare financing isnationalised in our country, thenational health insurance companywould have much easier financialand professional control.Surprisingly, this was not chosen by
volumes to be expected, is anabsolute must. In addition, a PACSmust allow for problem-freeupgrades, to accommodateunforeseeable increases in datavolumes.
As with pre-PACS solutions, digitalarchiving also offers fast access toexpensive local storage devices,which hold images from the last 3-6months, and a cheaper, bigger, long-term storage device with longeraccess times. ‘Pre-fetching’ avoidsextended waiting periods: scheduledexaminations are entered into thesystem hours, or days, before theytake place which means thecomputer automatically loads thepatient’s data from previousexaminations into the short-termstorage.
The most important impact of aPACS is that it reduces the timespan between an examination andfinal diagnosis. In the past, a delay ofseveral days between examinationand final diagnosis was not unusualbecause previously generated imageshad been forwarded temporarily tothe patient or a physician. Today,with an adequately sized PACS andwell-functioned pre-fetching, allimages are available within minutesat all diagnostic workstations. The‘down time’ of a radiologist and timeto final diagnosis are reducedsignificantly.
the participants, but decided so as todevelop local archiving and sharedata on request. Why? The main rea-sons could be defined as: ● concerns about legal issues ● data ownership ● responsibility for lost data (short
term)● authorisation ● concerns about archive security -
as in many countries, in Hungarydecades of medical image and dataarchiving is mandatory by law
● psychological reservations,because system administratorsand hospital managers prefer tohug their own data.
So how could the image data sharingproblem be solved without large cen-tral archives?
Current industry standards, likeDICOM and HL-7 are inadequate forthis purpose. These standards don’taddress issues like proper authorisa-tion, access rights, and on-demandfeatures for wide area network. Thesolution for the problems has to besome kind of data broker, and thatmust comply with the standards aswell as extend them to meet theneeds of this distributed environ-ment. Institution policies for dataidentification may be differentregarding study and patient identifi-cation that can be solved with a cus-tom mapping for data identification.Similarly, authorisation should becustom-made for the different insti-
tutes and/or users. Possibly a patientindex will be collected on the centralserver of the medical network thatwill efficiently help the functionsmentioned above.
Another issue is professionallydemanding visualisation of imagesthat complies with the workflow andorganisation of current needs.Sending the full data set is also pro-hibitive and time consuming, burden-ing network load. However, today, ITtechnology and solutions make itpossible to transfer studies as big as100 Mbytes within a few seconds.Visualisation of images might bedone on some DICOM workstations,but their local accessibility to multi-ple users is questionable.Teleradiology would provide anothersolution, nevertheless features cur-rently available are limited comparedto the dedicated DICOM worksta-tions. So, our purpose is to overcomethe limitations of either solutionsand to demand features (comparisonstudies, link feature, collaboration,dictation support, a remote tran-scription service, communicationwith local RIS, high resolution moni-tor, multiple monitor capability,MPR, MIP, basic 3D features) thatgive possibly the best versatility.
The same project is simultaneous-ly running in two other regions inHungary and it is planned to extendfor the entire country within the nextfew years.
continued from page 11
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O P E N M I N D S
Buying a PACS?Think first!
Considerable analysis must influence your choice of system,advises Helmut Ringl MD, of the Department of Diagnostic
Radiology at the University of Vienna General Hospital, wherelife without a PACS is now ‘unimaginable’
Ideally, after the implementationof a PACS the entire workflow runsin the background - a radiologist nolonger sees it. All images of thecurrent examination and all relevantpreviously generated images can beretrieved with a few mouse clicks.This means that a final diagnosis isavailable much faster and thus thelength of stay for our patients ispotentially shorter.
Very often a comparison betweenseveral previous examinations isnecessary to arrive at the bestpossible diagnosis, particularly whenthere are images of a previoussurgical intervention. Since a PACSfacilitates such a comparison -images are at your fingertips - thisoption is now being exercised morefrequently, which without a doubtimproves diagnostic quality.Furthermore, a PACS allows a quickand precise assessment of
mix-ups become less likely. Fullycompatible interfaces between thesystems are essential to ensureerror-free exchange of patient anddiagnostic data. Experience hasshown that the organisation andadministration of such a system iseasiest when as many programmesas possible are produced andupgraded by one single company. Ifthere are interface problems it isoften impossible to determine whichprogramme or company is thesource of the problem - a fact thatinevitably leads to conflicts andaccusations between the differentvendors involved.
Additionally, modern PACS areweb-enabled, which means imagescan be retrieved from every hospital-PC with an internet or intranetconnection and the appropriateaccess rights. This improvescommunication between thereferring and radiology departments.Most PACS already providetelemedicine modules, to be easilyintegrated on demand.
In a research environment theadvantages of a digital archivingsystem are obvious. Comparisonsbetween different examinations areeasily achieved and no longer
require additional costly prints.Moreover, measurements andquantification can be generateddigitally and images can betransferred easily without loss ofquality to presentations. In addition,pathologies can be searched for keywords.
The overwhelming number ofworkflow and organisationaladvantages notwithstanding, a PACShas one crucial disadvantage. Whensuch a system is completely down,the entire workflow comes to astandstill, and diagnosis is virtuallyimpossible. Therefore, it is crucialthat not only the system providesappropriate redundancy, but alsothat there are effective service andmaintenance contracts and/orcompetent technicians who canreact promptly to a problem.
In point of fact, a PACSsignificantly speeds up workflow andsimplifies the organisation of aradiology department. It has becomestandard in all medium-sized andlarge hospitals, and also in myhospital, the Vienna GeneralHospital, where it is now hard toimagine our daily radiological routinewithout a PACS.
PACS - workflow
Helmut Ringlpathological changes by thecomparison of current and previousexaminations - a particularlyimportant issue for hospitals with anoncology department.
With a PACS it is practicallyimpossible to lose x-rays.Consequently, there are considerablyless repeat images that put anadditional radiation burden on apatient and are costly. As soon as allmodalities are integrated into aPACS it is possible to re-organisestaff capacities. On the other hand,additional technicians are requiredto control and maintain the system.Obviously, a PACS has to interfacewith the hospital information system(HIS) and, if available, the radiologyinformation system (RIS). Patientdata in the HIS are transferred tothe RIS for scheduling purposes andthen forwarded to the individualmodalities. Thus, potential patient
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14
A D M I N I S T R AT O R S F O R U M
Financing aturnkey projectin Poland
The Kopernik Angio Centre, which opened last Novemberin Lodz, Poland, is a five million euro turnkey project. In 1998, the
radiology department at the Kopernik hospital neededmodernisation, but the hospital’s owner - the province of Lodz -
could not afford such a large investment and, as a publicinstitution, the hospital itself could not seek a financial loan.
A way around the problem was found 1999, by Dr Jozef Tazbir,the hospital’s director: a limited liability company would befounded, which could raise the capital. As a result, the im
Kopernika PPP (PFI) turnkey project was realised by TMSE-OD, incooperation with the finance company De Lage Landen International
B.V. headquartered in Eindhoven, The Netherlands andTMS Sp. Z o.o. representing Toshiba Medical Systems Europe.
The project included construction, two complete angiosystems (Infinix CS-I with FPD and VC-I with FPD), an ultrasound
unit (Aplio 80CV incl. Nice), 16 complete CCU beds and a fullycomputerised department (including a Cardiac PACS).
EH spoke with Dr Jozef Tazbir and Henio Sobiscewksi ofToshiba Medical Systems Europe (OD), about the project.
In Poland, loans must be requestedfrom a hospital’s owner, which isoften the provincial government.For this project, Henio Sobiscewski
explained, the bank required a guar-antee from the province. ‘The govern-ment, however, avoids issuing such aguarantee because it has a negativeimpact on the public budget.’ Theway around this was to found a limit-ed company to outsource the radiolo-gy services. ‘The entire radiologydepartment with the exception ofoncological radiology, was closeddown and the staff was laid off, thenimmediately hired by the company,’he explained.
‘One advantage in this is that wecan schedule the staff differently andmore flexibly,’ Dr Tazbir pointed out.‘In Poland, there is a law limitingworking hours for radiology staff to amaximum of five hours daily. Initially,that was intended to protect stafffrom radiation. The law applies to allstaff - physicians, technical personnelor MTAs - and severely limits workthat can be done in a radiologydepartment. The company took theentire personnel on board - but on afreelance basis. So, today, our radiol-ogy staff is not permanentlyemployed but provides radiologicalservices as freelancers. This con-struct allows us to schedule workinghours flexibly and according todemand.
The hospital agreed to thisarrangement, because that was theonly way to raise funds for the radiol-ogy department. Due to this conceptwe can now offer the entire range ofimaging procedures. We installed anew CT and an MRI and the ultra-sound and endoscopy equipment wasupgraded. This first project, whichalso encompassed a PACS, was com-pleted in 1999.’
Asked whether the negotiationswere only possible because Dr Tazbirwas administrative director of theKopernik hospital as well as manag-ing director of the company, hereplied: ‘ That is not entirely correct.In my function as administrativedirector of the hospital I representthe interests of the owners, meaningthe province. The hospital holds 86%of the shares of the company, whichhas its own managing director. Theother 14% is mainly in the hands ofprivate owners. That simply hap-
pened when the company was found-ed 16 years ago.’
In terms of financing the project,Henio Sobiscewksi said funds couldbe raised for two reasons: ‘First,because we had founded the limitedcompany, as explained, then becausethe hospital has a lot of potential - ithas 900 beds, all medical disciplinesare represented and it is obvious thatthe hospital needs a decent diagnos-tics department. On the basis of theoutsourcing and service concept, wecould develop a business plan thatlaid down how much money wasneeded for what, how many servicesand what equipment had to be pur-chased, etc. This business plan waspresented to DVI, an American finan-cial services company, because thePolish banks didn’t want to financesuch a project. Dr Tazbir and his col-leagues rushed from pillar to post toget the banks to provide the money.DVI was specialised in the healthcarearea and it finally took over the finan-cial aspect. The firm looked at thestrategic position of the hospital, forexample size, specialisations, co-operation with the university, poten-tial for expansion, and location, i.e.Lodz, a city with 1.5 million peopleand a big catchment area. Those wereall factors that influenced DVI’s deci-sion.’
However, a considerable setbackoccurred when DVI failed and a newinvestor had to be found. ‘We spoketo many banks in and beyond Poland,but none were interested,’ said HenioSobiscewksi. De Lage Landen, whichwas about to position itself in thehealthcare market, saw the project asa challenge and took over its nextphase.’ Although new in the Polishhealthcare market, De Lage Landenquickly analysed the hospital and,within a couple of weeks, a positivedecision could be taken on financingthe project. ‘The first step was thepurchase of a CT,’ he continued. ‘Asecond project concerned mammog-raphy; the third created the techno-logical framework for interventionalradiology: two angios and a cardiolog-ical ultrasound were installed and anintensive care unit with 16 beds wasbuilt.’
This changed the department’sstructure: whereas before, patientswere returned to a ward with nopatient monitoring system, now, after
an intervention a patient can remainin the 16-bed ICU overnight to bemonitored.
The business plan included theoption to admit private patients.‘Public hospitals in Poland try toadmit all patients, including privateones,’ Henio Sobiscewksi explained.‘Unfortunately, that is only possiblewhen the patient has a contract witha public insurer in addition to this pri-vate insurance plan, but even then,he’ll be put on a waiting list. In thePolish healthcare system you cannotjust open your wallet and buy anyservice you want. However, with acompany that’s possible.’ In theory,he added, just as a limited companycan issue an invoice, so can a publichospital, but that would violate thePolish constitution, which requiresthat all patients be treated equally.
So, is there a trend towards privati-sation in Poland? ‘That’s what thegovernment says it wants. But thefuture will show what measurespoliticians will in fact adopt in thatrespect,’ he replied.
DE LAGE LANDEN INTERNATIONAL B.V.Operating in over 20 countries throughout Europe, the Americas, andAsia Pacific, De Lage Landen specialises in asset financing and vendorfinance programmes and offers an array of commercial finance solutions.The firm’s particular focus is on food & agriculture, healthcare, officeequipment, IT and telecommunications and materials handling &construction equipment.
In 2004, the company expanded its European healthcare leasingcapabilities, aiming to focus on establishing partnerships with suppliersof various categories of medical equipment, e.g. diagnostic (X-ray, MRI,CT, PET and Ultrasound), as well as equipment for radiation therapy,patient monitoring, the operating theatre, laboratory, homecare(wheelchairs, beds, etc.), plus medical filing systems (PACS), anddentistry.
For the 2004 period, De Lage Landen predicted profit growth to €140million and a balance sheet total to €15 billion. Details: www.delagelanden.com
The ICU
The angiograph room
Ultrasound
Celebrating the openingin Lodz were Dr JozefTazbir; JohannesEenhoorn, director ofTMSE; PietGrootenboer, a memberof the EuropeanManagement Board ofDe Lage Landen, andrepresentatives fromToshiba, the universityand hospital and localgovernment
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Partnerships between clinicians,administrators and those whosupply IT systems are central tothe success of harnessingsophisticated InformationTechnology (IT) to improvehealthcare delivery - and the focusof a change in diagnostic serviceshas to be on its benefits to patientsand clinicians.
PACS is particularly relevantbecause the system is anoverwhelmingly important tool forspecialists - e.g. diagnosticclinicians, including chestsurgeons, radiologists andoncologists - since it will replaceexisting tools such as light boxes,film and traditional reading.
Any vendor that does notunderstand the importance ofworking together, as a team, tosupport the change in processesdue to a major PACS installation,becomes history. In such apartnership, certain issues must beaddressed for each stakeholder:
The patientsPatients are often not the firstaudience to be involved inhealthcare IT projects. However,the will and needs of patients inEuropean healthcare systems arecentral to the direction of thecurrent IT healthcare project inEngland - the Government’sNational Programme forInformation Technology (NPfIT) -which is also true whereverpoliticians are responsible forfunding and guaranteeinghealthcare delivery.
For patients, it is essential thatthey can choose the time and placeof their specialist appointments,including those for diagnosticimaging. Also fundamental to theongoing political will, plus hugeinvestment for the NPfIT, are‘benefits’ for patients. The patientscome first!
CliniciansEqually important are theclinicians (radiologists/radiographers, doctors/nurses)who understand that technologyprovides a positive way forwardand improves their ability to makeexpert decisions more cost-effectively and quickly.
Clinicians need to be involved inthe suppliers’ plans - however, inpractice this cannot mean thatthey can wholly redesign avendor’s system in each case.This, unfortunately, this is anexpensive legacy behaviour, whichis proving difficult to ‘unlearn’.
VendorsIn turn, vendors must recognisethat their systems must besufficiently flexible and universalin delivery, to address a wide rangelocation and interpretation ofclinicians’ needs. This may requirethem to adapt proven technologyand to explain that technology toclinicians who are not inherently,as has sometimes been alleged,‘anti-progress’ or ‘reactionary’.
Financial staff andadministrators This group has to recognise thatfor every euro they spend on IT -both software and hardware -
PARTNERSHIP IS IMPERATIVEClinicians+management+vendors: links in the chain mustbe strong to successfully integrate PACS, says Mark Simon
three euros has to be spent oneducation and training, and itshould be done enthusiasticallywhile improving the quality ofpatient care. To ensure a system isadopted, this not only involves apartnership, but even a ‘sellingrole’.
At ComMedica, the UK-basedhealthcare IT specialist firm where
I am Chief Executive Officer, weare playing an important rolewithin the National HealthService’s NPfIT. As a PACSprovider to an alliance led by theComputer Sciences Corporation,where we work alongside Kodak,we have seen the elements for thisco-operation from the first stage ofcontractual negotiations.
The success of the project todate results from:● Enthusiastic Government backing
and central funding for what isthe world’s largest IT project.There is a positive commitment totransform patient care
● The clinicians are organised andeducated in what is a far-reachingtechnical change project, and arebeginning to work closely withvendors
● Vendors being organised andensuring that systems link-upwith the integration companies,such as BT, CSC and Accenture,which are committed to long-termassociations with their hospitalcustomers
● Chief executive and financedirectors of healthcareorganisations, such as the UK’sNHS Trusts, being ready to setaside funding, both to implementthe technology and underwritethe necessary infrastructurechange programmes, particularlyeducation and training.
In England, there has been apromising start, although there stillwill be many bumps on the roadahead. However, the only wayforward is in partnership betweenthese constituencies week-by-week, month-by-month and year-by-year.Contact:[email protected]
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Marcus Ostländer, Radiology Solutions Business Manager, Europe, outlines theinnovations and strategies of the AGFA HealthCare Division in an EH interview at the RSNA
The Agfa HealthCare Division’s mottoin 2004 became Inspire, Transform,
Achieve, and the visual presentationat the RSNA, emphasised that IT andhigh-tech are at the centre of thefirm’s healthcare business, MarcusOstländer pointed out: ‘You won’t findany films at this exhibition stand. Ourstrategic orientation is towards theSolution Business, and our hospital-wide IT solutions cover not only radi-ology but also many other medicalfields, such as mammography, cardiol-ogy and orthopaedics. We are notlooking at individual products but atintegrations into comprehensivesolutions.
‘In Computed Radiography we havetwo new systems, the CR 25, a single-plate-CR system, and the CR 75, amulti-plate system, and both can alsobe used for mammography images.This is important for radiologists,because CR in mammography is cur-rently a very hot topic in Europe. Wealso have the brand new CR50, a com-puted radiography system with thekind of picture quality previously onlyachievable with DR. So, we have com-bined the flexibility of the CR systemwith the image quality of DRequipment.
‘The next most important topics inradiology are PACS and RIS,’ he con-tinued. ‘The flagship of the market,our IMPAX ES - Enterprise Suite -comprises integrated PACS/RIS diag-nosis solutions for radiology in gener-al, but also for mammography in par-ticular, including CAD. We also offerIMPAX solutions for cardiology andorthopaedics, which can be integratedinto the entire hospital concept. Thisincludes appointment planning acrossa hospital and, of course, the integra-tion of images with electronic patientrecords (EPR).
‘Our next generation IMPAX isbeing shown as a work in progress.One highlight of this further develop-
ment is the so-called persona-baseddesign. Our teams of experts haveanalysed how many users work in dif-ferent situations in a hospital andestablished different user types, so-called personas, from that analysis.These personas can be radiologists,clinicians, X-ray technicians or sys-tems administrators, and they allhave different requirements regard-ing specifications for visualisationand context of images, patient,department and systems information.We are not talking about special workstations for certain applications -every IMPAX user is given a cus-tomised desktop, depending on theirpersonal profile, which makes thesystem very flexible and efficient.This can be within the hospital or also
Asked about new developmentsinnovations in fields other than radi-ology, Marcus Ostländer mentionedorthopaedics. ‘We have taken compo-nents from the IMPAX environmentfor support in the choice of implantsin a filmless environment. For exam-ple, the procedure to replace a hipjoint with implants used to be carriedout by taking an X-ray and then try-ing out as many different templateson the X-ray as it took to find theright prosthesis. In a world withoutfilm we now have elegant digital solu-tions for this problem. X-ray films areno longer being used here - the imageis called up at a special IMPAXorthopaedics workstation where thesurgeon can choose from over 12,000implants for different uses, including
and particularly those that supportthe successful implementation ofPACS/RIS projects. ‘This begins withproject analysis, which determineshow the workflow functions, what theconfigurations look like and whatchanges are to be expected for theworkflows,’ he pointed out.
But what does the term health ser-vices mean in this context: where dothey begin, end, or overlap?
‘A good question,’ he replied, ‘see-ing how radiology is obviously inte-
the entire digital network and its con-nected components. This can thenprovide us with statistics on the vol-ume of data, systems capacity andutilisation - information usuallyrequired by senior radiologists, whoneed to know what’s happening in thedepartment, how workstations arebeing used and what capacities arelike. Hospital administrators alsorequire that information, to knowwhat the workloads and utilisation ofequipment are like and what trends
can be seen with the data vol-ume. The system can provideshort-term analyses or deter-mine long-term trends.
Another important feature ispro-active remote diagnosis andmaintenance, which practicallyprevents system down times,because corrective or error-pre-venting measures can be takenbefore the user even notices anerror. In other words, you haveextremely high stability with this
system.’Where would this control unit be
based? ‘Think of it less as a physicalcomponent but more as an intelligentsoftware solution that can be used, forinstance, by a systems administratorwith appropriate access, who is thenprovided with all the information andstatistics and who can carry outremote diagnosis and maintenancethrough communication with theAGFA service network via securegateways.
Moving on to the subject of cardiol-ogy, Marcus Ostländer said the firmhas entered into a co-developmentwith Heartlab ‘... a very renowned andsuccessful provider of cardiologyinformation management systems inNorth America. They develop plan-ning, diagnosis- and structuredreporting systems. Just like radiology,cardiology uses data from differentimaging modalities, and this data fromdifferent systems, e.g. MRI, ultra-sound and ECG, must come together.Our new system, which is integratedinto the design of the Impax environ-ment, facilitates this.’
Mammography was the last topic tobe discussed, and we asked about thefirm’s current competitive role in thisfield, to which he replied: ‘We have adigital diagnostics station, theMA3000, which is part of the Impaxrange and developed especially forwomen’s care, i.e. the workstation wasdeveloped for mammography imagesdiagnoses. It automatically supportsthe special requirements for imagingformatting and positioning, as well asthe indication of results for possibleCAD processing. Apart from CR sys-tems used in mammography we alsooffer digital direct-mammography - aparticularly exciting area because,although there has been a lot of digiti-sation, mammography is the last areathat, in most cases, is still done in theanalogue format.
‘The high image quality of digitalmammography - both CR and DR- hasbeen documented. But the real pointis that the digitisation of mammogra-phy will allow complete digitisation ofradiology as a whole. Conventional X-rays will be replaced by CR systems.The end result will be a digital image.However, mammography currentlystill works with films. So if you have tokeep the film processing side goingexclusively for mammography,switching to a digital system is a veryattractive prospect. Screening pro-grammes, which are currently thesubject of much discussion, requirehigh capacity and fast availability ofimages. We have a digital mammogra-phy solution that is complemented bythe appropriate diagnostics station,which, in turn, is integrated into theImpax environment.’
A new ultrasound system, made byAloka and named Alpha 10, has beendeveloped for clinical applications thatinclude general Imaging, radiologyincluding contrast ultrasound, OB/GYNincluding 4-D technology, and all otherclinically relevant niches, the firmreports.
Aloka, which has carried out R&D inultrasound for over 50 years, reportsthat, with its ProSound Alpha 10, it willintroduce new Ultimate CompoundTechnology, which has four elements.
The Compound Pulse WaveGeneratorThis is the full digital beamformer’s‘heart’, says Aloka. It enables thebeamformer to actually design thetransmitted waveform as an exception-ally precise beam, providing enhance-ments in focus accuracy, spatial andcontrast resolution. ‘Since all compo-nents are fully under digital control,Aloka’s Alpha 10 is ready for further
Prosound Alpha 10 to be launched at ECR 2005and new application of ultrasound,’ thefirm points out. ‘In addition, the accu-racy of the transmission/ receptiondelay is up to eight times higher thanconventional digital beamforming. Withthe aid of the Compound Pulse WaveGenerator, radiation of unnecessarysounds is suppressed, both in fre-quency and space. The results arehighly precise waveforms with excellentsuppression of artefacts.’
The Compound Pulse WaveGenerator, said to be unique in theindustry, is the best technologyapproach to get best results from thenew Compound Array Probes, the firmadds, explaining: ‘New CompoundArray Probes enhance focus precisionin the elevation direction and enablebeams to be focused homogeneously.This new technology is available in var-ious probes. Also new are Aloka’s 3-Dprobes, supporting the inbuilt com-pound 4-D engine. This combinationprovides highest performance level in
the industry dedicated for sophisticat-ed 4-D examinations in obstetrics andalso other applications.’
The firm describes the system as acompact, mobile unit with the smallest
footprint size in this segment and themost modern user interface - to ensurecomfort, safety and speed.
Various scan methods, image for-mats, store media and interfaces aresupported. New and additional probesexpand the wide range of applicationsincluding 4-D probes, Compound Arrayprobes, as well as acknowledged HSTseries probes.
Data storage meets the currentstandard. Apart from fully PC andDICOM standard support, data can bestored on a wide range of media, e.g.DV tales, DVDs and digital prints.Upgrades - The system’s flexible, scal-able architecture allows for hardwareand software upgrades. Raw Echo datacan be stored intact through digitalsignal processing, Aloka points out.‘Analysis utilising raw data by using RFsignals can benefit from these furtherdevelopments and will be available forlater, on developed new tools toanalyse the raw data.’
grated into all processes in the hospi-tal. Initially we are talking about ser-vices that are required for the digiti-sation of a hospital. At this stage, wealso act as consultants, asking how ahospital works, how the radiologydepartment works, where are theinterfaces with the clinicians, what isthe workflow like and what should itbe like, and what are the objectivesthat we are trying to achieve throughdigitisation. However, these servicesdo certainly also comprise technicalsolutions.
‘Our Solutions Monitoring andManagement Services (SMMS) canconstantly monitor the activities of
screws and nails. Digital superimposi-tion facilitates finding the idealimplant and planning the operation,with the plan made available throughweb-based image distribution in theoperating theatre. This has been inuse since the beginning of 2004, andwe have now extended that solutionwith a so-called trauma package -particularly suitable for treatingmulti-trauma patients. For example,the system provides a choice ofscrews for fixing fractures and sug-gests how they can best be used.’
In terms of networks and projects,Marcus Ostländer said the firm islooking at the healthcare services,
Integration forcomprehensive solutionsfor access from remote locations, withtransmission via intra or extranet. Ouruser-management is flexible in termsof system maintenance, the creationof user groups, user profiles and thedistribution of access rights for users,particularly in academia, where manystudents also work. We combineutmost compliance with the require-ments for security and access topatient data with simple, flexibleadministration. For instance, systemadministrators can check it over fromany location in the hospital, and setup users and adapt profiles.’
In November Agfa-Gevaert announced that it would acquire the private Bonn-based firm GWI AG,a leader in healthcare IT. Prior to this it had acquired the French healthcare IT firm Symphonie onLine.
Founded in 1990 by Dr Jörg Haas and Dr Rüdiger Wilbert, co-owners with General AtlanticPartners, a global private equity company, GWI develops and markets administrative and clinicalIT solutions for hospitals, in the German speaking region, through its fully integrated and scalableIT system ORBIS, which encompasses a fully integrated range of general administration, workflowand documentation systems, as well as highly specific clinical departmental systems. GWI’s cus-tomer base comprises over 2,000 medical sites in Germany, Austria, Switzerland and France.
By combining solid organic growth with a series of acquisitions, GWI, with around 890 employ-ees, expects to realise revenues of around 100 million euros in 2004. Taking account of theexpected revenues of GWI’s recent acquisitions, the German company BOSS and the French com-pany europMedica, the group’s 2004 revenues are estimated at 118 million euros, with an oper-ating result of 20 million Euros. Dr Jörg Haas and Dr Rüdiger will be in charge of the further devel-opment of this business within Agfa’s HealthCare division. ‘Due to our homogeneous product port-folio we can now drive forward the complete IT engine, including the complex range of applicationsfor the hospital, with a superior cost-benefit ratio,’ Dr Wilbert said.
A G F A A C Q U I S I T I O N S
NEW
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What PACS integration willmean to our servicesWorking in conjunction with Sicily’s biggest public hospital, theradiology department at The University Hospital of Palermo carriesout around 100,000 examinations annually and employs 35 physiciansand biologists and has over 50 students
At present, Professor Lagallapointed out, there is nohospital information system(HIS), but it is under
development: ‘The problem isthat not all departments areconnected to one system.Administration uses a differentone than we do,’ he explained.‘Basically, they use it to carryinformation. Ours is fasterbecause we need to transmitimages. Also, a PACS is beinginstalled, and we will integrate allthe different radiologicalmodalities into it. (A devicecalled PAXPORT will link singlenon-DICOM output modality intoa DICOM network for PACSimage management andarchiving, for the modalities thatdo not have network interfaces).
‘As it is still being installed, it’stoo soon to evaluate the effectsof the PACS on our efficiency.However, we believe that, in afew months, the new system willimprove patient care byenhancing the entiredepartment’s workflow.Additionally, archived images willhelp to streamline thedepartment’s educational andscientific activities. Who will run the PACS, and
will the staff adapt readily to
the new system?
‘A team of three or four people,probably IT personnel andradiology technologists, will runthe PACS in shifts. Agfa will trainthem and also provide supportwhen they need help. It’s toosoon to evaluate the effects ofthe new system on the staff, butbased on the experience of othercentres, we foresee that it willtake 3-4 months to use the RISand PACS systems properly. Ourgoal it to be high on the plateauof the learning curve within sixmonths. Then I think the PACSwill make it possible to improvethe work between the biggesthospitals in Sicily, because wewill be able to exchangeexamination results very easily -for research and study based onthe same information, andprobably for telemedicine.’
In an interview with EH,Professor Robert Lagalla, headof the department, discussedthe current installation of aPACS that will serve the centralradiology department, linkingwith all the hospital’sdepartments and services -a few kilometres away
Prof. Robert Lagalla
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MIRAX SCAN is a fully automated system platform fordigital histology that considerably facilitates theassessment of pathological specimens in clinicallaboratories. Instead of using a microscope to examinehistological sections, an automated scanner produces ahigh-resolution, digitised data set (digital slide) of thespecimen, providing pathologists with new methods:diagnoses and reports can be performed at thecomputer, several samples can be viewed and comparedsimultaneously. Network connections permit access todata from several users in different locations, thusenabling a second opinion to be obtained quickly. Inhospital environments, data can be integrated intoexisting information systems and archived.
The system allows processing of 300 slides in one
ADVANCEMENTSIN TELEPATHOLOGY
remote areas. Therefore, it is crucialto establish a network of pathologyexpert knowledge. One of the mostfascinating tasks of the GermanProfessional Association ofPathologists is to promote and fostersuch a network.
This is an ongoing process, becausewe have to adjust permanently torapid technological developments.Until recently, telepathology was arather limited application - we simplydid not have the required computer
scanned as a whole, or we have totake individual photographs at themicroscope.
To help our members to begintelepathology the associationinstalled a server, which, for person-nel and financial reasons, is located atthe Charité in Berlin. Currently, it isused primarily for the pilot project onmammography screening (see box).Every member of the association hasaccess to this server, to ask for or ren-der a second opinion. That means, at
image quality is acceptable and
comparable?
We provide guidelines concerning thetechnical minimum requirements, sothe images will all be of decent andcomparable quality. Can all pathologists afford
those technical requirements?
Definitely. There is just one issue thatmight pose a bit of a problem: thetelephone lines. Universities usuallyhave 100 megabit lines, but that is theexception. We try to achieve ade-
the actual scan. In short: this willenable us to work on screen just aswe do now under the microscope. What is needed to be able to
analyse digitised images with
the virtual microscope?
Just like with any other teleconsulta-tion project there are certain prereq-uisites needed: separate from theregular IT equipment a consultationserver is required to up and downloadimages. To download images youneed a so-called image streaming
storage capacities. The data volumesgenerated and processed during thedigitisation of a single microscopicslide are many times larger than thoseof an X-ray image, which is basicallydue to colour and detail. In a pilotstudy in our institute we found thatthe average data volume of onemicroscopic slide is 800Mb - onemicroscopic slide! For certain diag-nostic procedures such as breast can-cer we need ten or twelve microscop-ic slides. However, today storagecapacities have grown manifold, andat the same time prices have droppedsignificantly. Consequently, storagecapacity is no longer the limiting fac-tor it was a couple of years ago. Thesecond important aspect is the scan-ner. The microscopic slide has to be
his microscope the pathologist createsa digital image of the specimen inquestion in different magnifications,and stores them on his hard drive.From there he downloads the imagesonto the server. Within a predefinedtime span, a competent colleague willrender a second opinion. For us, this isthe only way to explore the possibili-ties as well as the possible limitationsof telediagnostics. How far can we go?Is the diagnosis based purely on digitalmaterial as good as the immediatemicroscope diagnosis? We don’t knowfor sure yet, but I assume it will bevery close. Current technologicaldevelopment has shown that digitisa-tion is the way of the future.How is it guaranteed that, when
downloaded to the server, the
quate results with 10 megabit lines.Even 2,5 megabit and DSL works -but then the data transfer does take awhile.Will the virtual microscope, a
new development, play a
significant role in the future?
Indeed, this is a fascinating develop-ment, which is still in its pilot stage. Iworked with such a virtual micro-scope for three months. The excitinginnovation is the scanning technolo-gy. This was developed by a workinggroup in Budapest, and then Zeisscame on board and launched it underthe name Miraxscan (see box). Themicroscopic slide that we usually seeunder the microscope is scanned.The brilliant innovation is the factthat one does not have to generate,store and transfer images of severalmicroscopic slides but only one. Andthen I can enlarge this image on mycomputer, in the same way that I usu-ally do under the microscope. Thatworks wonderfully. This solves aproblem that, until now, was consid-ered insoluble. Moreover, this scan-ning technology works at an accept-able speed. Previously we neededabout an hour to scan one microscop-ic slide. Now we need one to threeminutes. You can prepare a whole set;it will be documented and markedwith all the necessary data prior to
software to enlarge the images. Itworks amazingly well. We tested itbetween the Charité and our institutein Gelsenkirchen. This scanningequipment is presently expensive, car-rying a price tag of about 150,000euros plus the storage devices.
One of the other great advantages ofthe virtual microscope is archiving. Weare asked to archive every singlemicroscopic slide for 10 years. Theseare glass objects, so we have to storetons of material. And we have to beable to retrieve every single slidequickly. Digital archives would makelife much easier.Could a digital archive really
replace a physical one?
We are not really sure about that yet,but I have a hunch that, in the end, thedigital archive will replace the physicalone. Consider this: in an intricate pro-cedure water is extracted from thespecimen and replaced by paraffin. Inthe next step this solidified specimenis embedded in a larger paraffin block.Then very thin sections are cut off thatblock and stained. These slices areused for diagnosis. We are increasinglyasked to also archive the ‘leftovers’ ofthe paraffin blocks from which we cutthe sections. With a digital archive anda physical archive all possible ques-tions that might turn up later can beanswered. With a digitised archive
‘Teleconsultation means the profes-sional exchange between patholo-gists,’ explained Professor Schlake.‘Pathology is a very broad medicaldiscipline, and therefore we have nei-ther the financial nor the personnelresources to ensure that each pathol-ogist is an expert in each aspect ofthe field. However, hospitals andphysicians need the services of local,or at least regional, ‘general’ patholo-gists. In addition, we need access tospecialist knowledge - for example, inlymphoma or liver diagnostics. Iftelepathology allows a regionalpathologist to co-operate online witha reference or consultation centre forlymphomas, the entire range ofpathology expert knowledge and ser-vices would become available even in
6 µm thick paraffin section. Organ specimen: (human) colon tumour, Dye: P53. Application:tumour research. Nuclear P53 labelling in a cell cluster of a colon tumour. Authors: L.Andries and M. Kockx HistoGeneX, Belgium
Miraxscan
batch without user intervention, with digitisationrequiring 5-20 minutes, depending on the size of thesection. The high-resolution system monitor providesthe user with the same field of view as the microscope,but offers better ergonomic convenience than viewingthrough an eyepiece. The software permits fastscreening of specimens on the monitor, marking ofregions, compilation of reports, and teleconsultationvia the Internet. This makes histological evaluation ofspecimens and preparation of the diagnostic reportindependent of place and time.
MIRAX SCAN is a joint development of Carl Zeiss AG,IBM HealthCare Solutions and Hungary-based3DHISTECH, who developed the system with clinicalusers.
Prof. Werner Schlake
19
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TELECONSULTATION IN MAMMOGRAPHY -THE PILOT PROJECT
Professor Werner Schlake, President of the Berufsverband
Deutscher Pathologen (German professional association
of pathologists), in Gelsenkirchen, has described
teleconsultation as the most significant application of
telepathology. In an EH interview we asked how this works
and what the future holds
Mammography screening is currently being introduced in Germany.Whenever an abnormality is detected during the mammography, a tissuesample is taken for examination by a pathologist. When the legal frame-work for the mammography screening programme was developed it waspathologists themselves who suggested making a second opinion manda-tory - to enhance diagnostic security. Therefore, the German professionalassociation of pathologists installed a teleconsultation server at theCharité in Berlin.
The current pilot project aims at determining the possible fields of appli-cation, as well as the reliability of teleconsultation. Direct comparison ofthe conventional method of mailing the specimen to a colleague for a sec-ond opinion with a telepathology procedure rendering a second opinion onthe basis of exclusively digital material will enable assessment of whetherquality differs between the two methods.
All pathologists who have internet access, a current browser version andthe necessary equipment to generate digital images of the specimens, canparticipate in the project. Over a period of about six months, all mammog-raphy cases submitted will be diagnosed conventionally and digitally. Thesending pathologist downloads the images and the usual information tothe teleconsultation server. For the second opinion, a reference patholo-gist is randomly selected among the participating pathologists. The fol-lowing data will be collected: ● Diagnoses: first diagnosis, second opinion, conventional and digital,
anonymous case data● Evaluation of the handling procedure through a user survey.
This study is pan-European, the first large-scale project on the quality ofteleconsultation. An interim report is scheduled for presentation at theannual pathologists’ congress, and the association expects final results bythe end of 2005.
alone that might not be possible. Forexample, many large institutesarchive the paraffin block when can-cer has been diagnosed. Recently, anew treatment for a certain kind ofbreast cancer was developed: if thetumour cells carry a certain amountof HER2/neu-proteins, an antibodytherapy can be initiated. For thewomen concerned this is an interest-ing alternative, since with this anti-body therapy a surgical interventionis no longer required. If a woman who
the microscope. Therefore I believethat digital microscopy will replacecertain core tasks of the microscope.But first we must prove that the digi-tal procedure provides the same levelof quality as the manual one.Is frozen section an issue in
telepathology?
Yes, this has a number of basic prob-lems: first, it is performed by non-pathologists. Tactile sensitivity isvery important in a pathologist’swork, so it’s an integral part of his
proliferation marker, which tells uswhat percentage of cells are ingrowth stage. We can find outwhether a tumour grows fast or slow.Here, digitisation offers many possi-bilities. So, is this the end of the
traditional microscope as we
know it?
I think that the digital procedure willreplace the microscope for certainroutine diagnostics. When we did thepilot study in our institute we foundthat digitisation offers a number ofpossibilities that the traditionalmicroscope can’t provide. For exam-ple, I can display on screen an entireoverview of several specimens on onescreen - extremely important in somecases. Or if one has differentlystained tumour sections, you canview and compare all of them on onecomputer screen. I can’t do that with
training. The eye must be trained aswell. Consequently, the tactile sensi-tivity and eye of a pathologist arequite different from that of a surgeon.Second: the staining procedure of afrozen section is limited. The frozensection does not allow the sophisti-cated technical procedures a paraffinblock can undergo. Third: the num-ber of intra-operative frozen sections,e.g. in mammography, is decliningrapidly because breast cancer pre-vention and diagnostics start at a
much earlier age. Consequently,malignant tissue changes are alsodetected earlier. If a physician sus-pects a tumour that he can neithersee nor feel, he can perform a frozensection - but only of one or two tinyareas. The selection of these areas israndom. Maybe these frozen sectionsdo not contain any important find-ings, but when later the tissue isexamined more closely, the patholo-gist does find suspicious foci, thenyou have to tell the patient, sorry, wemade a mistake in our initial diagno-sis. That is very frustrating.Therefore, frozen sections are todayno longer an option with tiny lesions.Consequently, frozen section is cur-rently no issue for telepathology.We’d rather focus on the really innov-ative potential of telepathology: tele-consultation. It is cheaper than thetraditional method of sending out aspecimen by mail or courier, andtherefore an attractive option interms of costs. Not to mention thefact that it is much faster and easierto handle. However, most important-ly, teleconsultation offers the pathol-ogist - wherever he is - access to spe-cialist knowledge, and this meansthat the patient, physician and localpathologist can benefit from state-of-the-art diagnostics.
has been diagnosed with breast can-cer a few years back considers such atreatment, the physician first has toanalyse the cells. To do so, he canexamine the original paraffin block -if he archived it. If not, the womanhas to undergo another biopsy.Therefore, we are asked to archive allblocks for 15 years. Digital archives -that would be the ideal solution.Does digital archiving also open
up new perspectives on
quantitative evaluation of
specimens?
Yes, with virtual microscopy we can,for example, quickly determine per-centage distributions. A software-based system can tell me that, forexample, 20% of the tumour cells areoestrogen positive, and 80% are neg-ative. Today, we use more or lessvague approaches for quantification.We can also perform analyses using a
Gemini - the first and only open PET/CT scanner - has helped to pioneermedical hybrid technology. Developed by Philips, the firm reports that demandfor this technology has been substantial: ‘Clinicians commend the scanner’simage quality as well as its ability to perform true full body scans while alsoenabling them to more accurately pinpoint the location of tumours.’
Now, at the ECR, Philips is showcasing its latest addition to the Gemini line- the Gemini GXL PET/CT system. ‘This leverages breakthrough advances inPET technology, to consistently provide superior image quality across a widerange of patients and applications, with entirely new levels of throughputperformance,’ Philips explains..
The GXL also features the OpenView gantry, an innovation that provides anopen airspace between the CT and PET acquisition components. This not onlyallows imaging flexibility and clinical access to patients, but has also provedmore reassuring for people being scanned: the design has reduced patientrejection rates.
Deepak Malhotra, PET marketing director for Philips Medical Systems,points out: ‘The leading-edge technologies in Philips Gemini GXL enhancethroughput while providing high image quality at low dose levels today, andprepare physicians to leverage the benefits of new radiopharmaceuticalstomorrow. Furthermore, the system is offered in three CT slice configurations- 6, 10 and 16 slice - allowing customers to choose the right solution for theirsite today and upgrade to a higher CT slice configuration later, as theirclinical needs grow.’
HYBRIDTECHNOLOGY
The open PET/CT scanner
EUROPEAN HOSPITAL
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