Dollars and sense in innovation

Give me a good gadget and I'm happy. I think a lot of people in radiology would say the same thing. It's the reason crowds gathered 15 years ago to see 3D reconstructions revolving aimlessly in space. It's why MR was a hit in the early 1980s.

Historically, good gadgets seem to succeed, even when those technologies are ahead of their time. Take 3T, for example. A few years ago, vendors cast 3T as the new standard bearer of high-field MR. "If you're going to buy only one MR in the next six or eight years, you would be well advised to buy a 3T" - or so the pitch went. And it worked. In the sluggish MR market of the last several years, 3T has bucked the trend.

Other times, however, an advanced technology stumbles and bumbles for years on end. A decade ago I was certain that digital radiography would take the world by storm. X-ray was the backbone of medical imaging and sorely in need of enhancement.

Radiography tables and chest stands were 10, 15, even 20 years old at some sites. DR, with its solid-state detectors, was the answer and the market seemed primed to accept it. The alternative to DR, computed radiography, didn't seem like it would provide much competition. Its phosphor-coated plates and centrally located readers didn't offer much of an advantage over film. And it had been around for years. DR vendors argued that their technology would vastly increase productivity, an argument DR salespeople are still making today. And why? Because CR didn't go away. It boomed.

You could say that radiography is too cost-sensitive for systems built around expensive solid-state technologies to catch on. But that was exactly the reason given 30 years ago by ultrasound manufacturers for sticking with their low-cost, low-performance scanners--only to have the argument come undone with the release of a 128-channel scanner that forever changed the ultrasound community.

So how do we tell which technology will soar commercially and which will flounder? The deciding factor, without a doubt, is economics. And, despite appearances, it always has been. In the cases of 3T, CR, and ultrasound, economics made the case.

Cost concerns continue to sweep 3T upward, as prospective customers worry about obsolescence. They are behind CR's dogged hold on x-ray, as this technology stretches the life cycle of analog radiography systems, delivering digital images on the cheap. The extended clinical use of ultrasound, made possible by advanced scanners, expanded the economic viability of this modality.

Much the same can be said for other technologies that have taken hold in the marketplace. PACS make medical practice more efficient. MR and CT speed the diagnostic process, as they guide less costly and less invasive interventions.

Why is it, then, that we react with such disdain to the thought that economics should be taken into account when developing an imaging technology? We need to acknowledge the role of economics in medical practice, not grudgingly but enthusiastically. We need to use current practices in medicine as benchmarks and then compare them to procedures made possible by new technologies. Those comparisons should consider whether new ideas are as effective--or more effective--clinically, but also how they compare in cost. And we can't afford to be humble about the findings.

Imaging is under attack because it is perceived as a cost center. We need to prove, whenever possible, that it is a center for cost savings, as well as a critical element for quality healthcare. Or else the harassment being leveled at medical imaging now will pale in comparison to what is yet to come.