Living the imaging life large the digital way

In a previous article ("It won't be long before you will not be able to live without a PDA," Sept. 2001, page 23), we discussed the myriad applications of PDAs in medicine, with a specific focus on radiology. While PDAs offer radiologists a portability never before experienced, they represent just the tip of the iceberg, hinting at the futuristic manner in which computers will touch our professional and private lives.

Many radiology providers have embraced the concept of going filmless, but most adopters keep the practice paradigms and mindset inherent to a film/paper-based world. This has the undesired effect of minimizing the true potential of "going digital," whether it pertains to optimizing workflow and productivity, minimizing medical/interpretation errors, improving the timeliness of communication, or enhancing report content. Users must be willing to advocate major changes in how they implement these digital applications.

In addition to PACS and digital radiography/mammography, the digital arsenal includes electronic decision support tools (such as CAD), speech recognition and structured reporting, artificial intelligence techniques, and the electronic medical record. As new challenges arise, the radiology community must take a proactive role in adaptation. We must understand how technology developments can be utilized to enhance our everyday lives. In an address at the California Institute of Technology in 1931, Albert Einstein asked, "Why does this magnificent applied science (technology), which saves work and make life easier, bring us so little happiness? Because we have not yet learned to make sensible use of it."

To gain insight into this conundrum and find a little humor at the same time, we have created a fictionalized day in the life of our favorite radiologist, Dr. Eliot. In one scenario, Dr. Eliot functions in the traditional film/paper-based world. In the other, he takes advantage of computer applications to enhance both his professional and private lives. While the scenario is purely fictional, it isn't far from reality. In the end, we hope you come to the same conclusion we have.

ANALOG RADIOLOGIST

We find Dr. Eliot fast asleep in the comfort of his bedroom. The phone has been turned off because Dr. Eliot finds that middle-of-the-night phone calls are anxiety-provoking. Instead, he relies on his beeper for on-call communication. The hospital emergency room has been frantically trying to reach Dr. Eliot for the past hour but has been unsuccessful. Dr. Eliot has forgotten to change the batteries in his beeper, which has been rendered functionless.

The emergency room physician, upset that the radiologist on call is not available, phones the chief radiologist, Dr. Max. The unexpected call to the Max residence awakens Mrs. Max, who shares with her husband her extreme displeasure. In an attempt to maintain damage control, Dr. Max throws on his clothes and speeds to the hospital to assuage the anxiety of the ER physician. In the course of this frantic rush, Dr. Max gets pulled over by a police officer for driving erratically and is forced to take a sobriety test. He arrives at the hospital 30 minutes later (with a police escort), and apologizes profusely to the ER physician, assuring him this will never happen again.

After completing the consultation, Dr. Max also tries to reach Dr. Eliot via telephone, without success. He decides to go to his house to investigate and proceeds to awaken the entire household at 3 a.m. After being chastised by his employer, wife, and kids, Dr. Eliot decides to go to the 24-hour store to purchase new batteries for his beeper. While fumbling in the dark to find his clothes, however, he trips and unplugs the alarm clock. An hour later, he returns to his bed, hoping to salvage three hours of sleep. He glances at the alarm clock and sees that it reads 3:15 a.m. As he drifts into sleep, he smiles at the thought that he has unexpectedly gained an extra hour of sleep.

When Dr. Eliot awakens the next morning on his own volition, he wonders at the absence of his customary morning wake-up from his trusty alarm clock. When he sees the time on the clock has not changed, he jumps out of bed, only to realize he has overslept by an hour. Without his usual cup of coffee and jelly doughnut, he throws on some clothes, unaware of the impending rain, and runs out of his house in a panic. His wife sees his disheveled appearance and can only shake her head. He is already running 75 minutes late for his scheduled 8 a.m. breast needle localization.

On the way to work, Dr. Eliot experiences a major traffic jam due to an accident. He attempts to negotiate his way through an alternate route. After getting lost for an additional 30 minutes, he arrives at the hospital an hour and 45 minutes late. When he reaches the radiology department, he is greeted by the sleep-deprived Dr. Max, who had to miss his morning meeting with the hospital CEO in order to perform the breast needle localization Dr. Eliot has missed. In addition, the surgeon is livid because the needle localization delay bumped him in the OR schedule.

After the morning hoopla settles down, Dr. Eliot steadies himself with a belated cup of coffee and begins "melting" the stack of CT exams. Ten minutes into the exercise, the friendly gastroenterologist calls from the ICU in search of the report from a GI bleeding patient who had an abdominal/pelvic CT the previous afternoon. Dr. Eliot recalls seeing the case at the end of the day and remembers putting it aside in the hopes of getting the CT technologist to perform some angiographic reconstructions. He decides to render a wet read in the meantime and quickly skims over the 1000-image study. His presumptive diagnosis of portal venous hypertension is rebuffed by the gastroenterologist, who tells him that his diagnosis makes no sense and is totally contradicted by the clinical history he had provided with the paper requisition, which the CT technologist had mistakenly thrown in the trash.

Later that day, Dr. Eliot gets a call from Dr. Jones, a family practice physician who is calling to protect him from a potential embarrassment. It seems that a report he had dictated and signed off on had contradictions between the body and the impression. In the body of the report it stated that "no free air exists." However, in the impression it stated, "Free air exists." The consulting gastroenterologist, who had punished Dr. Eliot earlier, had ordered a STAT surgical consult on the basis of the report's impression. The consulting surgeon, the bumpee of the delayed breast needle localization, had left an office full of patients, only to find that the cause of the STAT consult was a typographical error. Dr. Jones wanted to warn Dr. Eliot that an incident report was in the works and that he might want to issue an amended report.

An hour later, Dr. Eliot realizes that he has an important meeting with the hospital administrator regarding pending equipment purchases for the next fiscal year. The meeting had been postponed twice before, and it must take place today because the hospital finance committee is meeting that evening for final approval of the proposed budget. Unfortunately for Dr. Eliot, in all the earlier commotion, he has left behind the report he wrote on his home computer and will have to wing it. The meeting does not go well, and the hospital administrator asks Dr. Eliot to be better prepared in the future.

No additional catastrophes occur at work and Dr. Eliot leaves at 5:30 p.m. for his anniversary dinner with his wife. A summer rain shower, which had been predicted, drenches him. Forced to decide between heading home to change and being late or going directly to the restaurant, he chooses the latter. Once at the restaurant, however, he realizes he has left his wife's anniversary present on his dresser. The dinner does not go well, and Dr. Eliot ends his horrible day by sleeping on the living room couch, trusty alarm clock by his side.

THE SAME DAY-DIGITALLY

Dr. Eliot is awakened by his watch alarm. It appears that his beeper was out of commission and had transferred a "failure to communicate" signal to the network, which in turn notified him via his computer watch. At the same time, his PDA has received the transmitted teleradiology images from the emergency CT exam, which he promptly calls in to the ER physician, who thanks him for his prompt follow-through.

The next morning, his alarm clock goes off on time, despite a transient power failure, as the computer within the clock self-corrects the time. While Dr. Eliot is dressing, the computer chip in his shirt tells him via a color change that rain is anticipated, and he remembers to bring an umbrella. In addition, his PDA alerts him about his anniversary dinner, along with a reminder to bring with him the emerald necklace he has bought for his wife.

He leaves the house on time, in anticipation of his 8 a.m. breast biopsy. On the way to work, he encounters a traffic backup due to an accident. He turns on the GPS (global positioning satellite) system in his car and successfully navigates an alternative route, arriving at the hospital at 7:50 a.m.

The biopsy goes well, and Dr. Eliot proceeds to begin reading CT exams using the multiplanar 3D processing workstation. During the readout, he is able to perform segmentation analysis of the data set along with "on the fly" MIP reconstructions. The combination angiographic and CT colonography images reveal an arteriovenous malformation within the transverse colon, which explains the patient's acute GI bleeding. He sends an e-mail alert to the referring gastroenterologist, with attached annotated reconstructed images, highlighting the area of pathology. Within five minutes, the referring gastroenterologist responds with a thank you message on Dr. Eliot's digital beeper.

Dr. Eliot chuckles to himself as he thinks about how it was in the old analog days, when physicians consulted in the radiology department and report turnaround was measured in days, not minutes. Just before signing off on the case of the colonic AVM, Dr. Eliot decides to add it to his digital teaching file. He logs onto the Internet, accesses the national Library of Medicine Web site, and runs a quick literature search on new therapies for AVMs. He bookmarks two interesting articles, along with a review article from Radiographics on vascular malformations within the GI tract. He then goes to the RSNA Web site, accesses MIRC (Medical Image Resource Center), and deposits images from the current study while accessing other cases of GI AVMs. He downloads the collective series of cases onto his own digital teaching file and burns the images and references onto CDs for the referring gastroenterologist and primary-care physician.

While "garbaging out" a few DX studies later that day, Dr. Eliot is alerted by the speech recognition software to the fact that a discrepancy arose between the report body and impression. Intelligent software picks up the little mistakes that he often overlooks. He can remember how frustrating it used to be in the old days, with all the errors and delays associated with manual transcription. As he finishes reading out the ICU electronic folder, Dr. Eliot's PDA alarm goes off, notifying him of his 4 p.m. meeting with the hospital administrator, the closing numbers on Wall Street, and directions to tonight's anniversary dinner. He downloads the ROI spreadsheet he had prepared the previous night onto his office PC and e-mails it to the hospital administrator along with bookmarks to the vendor's Web site. By the time he gets to the administrator's office, the analysis has been reviewed and accepted. The administrator has already e-mailed the report and conference-called with the finance committee, which has unanimously approved the lease.

With nothing else to do, Dr. Eliot leaves work a little early, stops by the florist, and arrives at the restaurant to meet his wife with a dozen roses in his arm. When he gives his wife the emerald necklace, she cries for joy.

AFTERMATH

While we have taken creative license in this fictitious day in the life of Dr. Eliot, a few important points need to be emphasized. Whether we are ready or not, computers have changed and will continue to change the way in which radiology, and all medicine, is practiced. Radiologists can no longer wait it out, hoping that computers will fall by the wayside. In fact, computer applications will completely change all aspects of everyday living.

The concept of ubiquitous computing was developed by Mark Weiser in the Computer Science Lab at Xerox PARC. In his pioneering work, Weiser and associates described three waves of computing. The first consisted of the mainframe computer, where one computer is shared by several people. The second computing wave has introduced the personal computer, where each user has a single computer. The third wave, which we have not yet entered, is ubiquitous computing, where one user utilizes hundreds of individual computers. These hundreds of wireless computing devices will become intertwined in all aspects of our lives. The way we view computers changes from a stand-alone instrument to a technology so embedded in our lives that it becomes invisible.

We can compare these three computer waves or eras to the paradigm shifts within radiology. The first era, which lasted for almost 100 years, was the traditional x-ray department, which operated with film, paper, and alternators (one single display tool for multiple users). The second era, which we are just entering, consists of PACS and the HIS/RIS, where data are stored and displayed in an electronic medium (each radiologist typically has his or her own individual diagnostic workstation). The third era, which we will undoubtedly enter in the near future, will consist of the electronic medical record, where all data are digital and can be instantaneously accessed regardless of location.

Medical data, both textual and imaging, will become ubiquitous and accessible through a wide variety of computer technologies, including PDAs. The ubiquitous phase will entail a medical world of fully connected devices, with cheap wireless networks everywhere. This will create several technical challenges for the users and facilitators, radiologists and IT personnel. The first challenge is bandwidth, because ubiquitous computing envisions hundreds of wireless computers in every office. The second challenge is the ability to deal with increasing mobility. Existing networks assume a user's fixed network address. Making the transition to a world where computers move between networks will undermine existing protocols like TCP/IP. New protocols will therefore be required. A third technical challenge is the operating system, which will require the user to migrate applications from one system to another seamlessly and transparently.

What will this futuristic workplace look like? The world of computers will shift from external to embedded technologies. Computers will become embedded throughout the physical environment: in the walls, chairs, light switches, desktops, even clothing. A transition will occur from "thin clients" to "thin servers," so that each wireless computer will function as an individual Internet server. This will transform our perception of computers beyond our level of consciousness, effectively making them invisible.

Electricity is an example of a technology that has become invisible. When it was first invented, people marveled at the way electricity could be used to illuminate and serve as a source of power. As its everyday applications increased, it essentially faded into the background. Another example of ubiquitous technology applications is the microprocessor, which is embedded in all utilities: the alarm clock, microwave, TV remote control, and even children's toys. If we were to network these technologies together and tie them to the Internet, millions of information sources and delivery systems would converge within your home and office.

"The powers of technology appear to be unlimited. Major changes in thought have occurred as consequences to technological advances," said D.S.L. Cardwell in Dictionary of the History of Ideas.

Those words, written in 1973, become ever more prescient today.

Dr. Reiner is director of radiology research, and Dr. Siegel is chief of radiology and nuclear medicine, both at the VA Maryland Health Care System.