MR

Radio-Diagnosis & Imaging

MR microscopy is plausible; fusion of Tractography with Functional MR and MR microscopy can one day lead to real-time evaluation of processing in individual neural circuits

"Radiology has been re-invented. It is today the most technology intensive field in medicine" - Dr Lovneesh Garg HOD and Senior Consultant Radio-diagnosis and Imaging SPS Apollo Hospitals Ludhiana

The last few decades have seen phenomenal developments in the discipline of radio-diagnosis and imaging. The exhilarating tempo of the technical innovations that have been brought to the field of imaging by physicists and technologists has outpaced the adaptive responses of the teaching institutions, radiology personnel and radiology administrators to the paradigm shift.

Technology transfer to India from the west, in the particular discipline of radiology, has been faster than in other medical specialties. While it is true that the organised healthcare sector as well as stand-alone, individually owned diagnostic centres in India have been very quick to incorporate the top-of-the shelf equipment and Indian radiologists and radiology technicians have been fast in gaining expertise in the practical usage and application of the latest, highly advanced imaging techniques, sadly, a holistic, planned and strategically designed approach to acquisition of ever-evolving equipment, comprehensive understanding of new technologies and imaging protocols, application of these to actual clinical scenarios, the new patient safety concerns demanded by the latest products and the administrative restructuring required for judicious utilisation of the expensive equipment has not been evolved in the country. Consequently, there has been an adhoc, haphazard and non-uniform development of radiology in various part of the country, with under-utilisation of the diagnostic armamentarium actually available at most centres, and usually patient - and staff - safety concerns are given a go-by.

While, we in India have to develop and evolve our own strategies and policies in this regard, we don't have to reinvent the wheel itself. These concerns have been the focus of deliberations at various fora in the west. Following are some suggestions to aid hospital administrators and radiology managers, educationists' radiology equipment industry /vendors, radiologists and technicians in responding to the rapidly advancing and sophisticated technologies in the context of increasing legal regulations, burgeoning clinical demands and economic pressures.

Coupling between Creators & End-users

A formal, structured mechanism should be created for close coupling between medical colleges / universities, institutes of technology (like IITS, IIS etc.), R&D centres of imaging equipment industry, radiology application specialists and the end-users, i.e. the radiology personnel. This will help in making the equipment more user-friendly and also prevent under-utilisation of the capabilities of the available equipment. A coupling of this kind is common in the west but is only rudimentary in India, consequently, adaptation of equipment and processes to local conditions and infra-structural bottle - necks suffers, sometimes with catastrophic results. For instance, the MRI quench-pipes in India often get clogged by rain-water, pests etc.; a simple solution is to point the vent - downwards and cover it with a fine mesh.

Re-structuring of Radiology Training

Radiology has been re-invented. It is today the most technology intensive field in medicine. It extensively utilises the tools of Information Technology. Images are read from sophisticated PACS systems in film-less departments; computer networking is used for instant transmission of thousands of images; processing of images on work-stations demands IT related competencies; Computer Aided Detection is being used to aid diagnostics (e.g. for detecting micro-calcification in mammograms), thereby improving objectivity and consistency in interpretation.

Secondly, sophisticated modalities like MRI and MDCT, especially the advanced applications like Diffuse Tensor Imaging; Functional MRI etc. require an in-depth understanding of the underlying principles of physics.

So, there should be emphasis on IT and physics in radiology education curricula for radiologist and technicians; radiology administrators should pro-actively create mechanisms for bridging the gaps in knowledge and upgradation of skills in these spheres and for organising life-long learning around the clinical needs at the work-place.

Functionality of Work-flow Design

The workflow at the radiology facility has to be intelligently designed so that it is functional, patient friendly, promotes efficiency and, thereby, improves productivity.

For instance, reporting station of at least one radiologist should be adjacent to the CT/MRI console so the radiologist can tailor the study to the requirement of the case and do real-time monitoring; this enables a targeted, problem-solving imaging paradigm and minimizes patient - re-calls for deficient studies, saving time, man-hours and money.

Holistic, Multi-disciplinary Approach

Hospital administrators have to promote inter-disciplinary co-ordination; the touch stone of success of a radiology centre is the number of clinician visits calls to the radiologist for case - discussions; radiology cannot be practiced in isolation - if the imaging protocol is not tailored to the requirements of a given case and the radiology report does not reflect sensitivity to the referring clinicians concerns and queries, radiology becomes barren. This in turn demands close interaction between radiology personnel, clinicians, pathologists and patients. A conscious effort for promoting such a mindset and improving the communication skills of radiology personnel has to be made. The magic begins to show very soon as the clinicians become psychologically dependent on the radiologist for sorting out their clinical problems and that translates into efficacious utilisation of equipment with increased throughputs.

Quality Management (QM)

QM will increasingly become a key-issue in ensuring survival in an increasingly competitive market and a more legally stringent environment.

QM comprised Quality Control (QC) and Quality Assurance (QA). QC involves regular surveillance and testing of imaging equipment and evaluation of imaging quality. QA is a more comprehensive program and involving systematic collection and analysis of data.

Quality management may sound a boring, tiresome, bureaucratic process but it translates into higher patient satisfaction and, thereby, yields a competitive edge. Moreover, if trends in the west are an indictor, re-imbursements will, at least partly, be based on the quality and efficiency of service (pay-per-performance) and regulating agencies will start demanding active QM programs, for instance, the American Board of radiology requires that a Practice Quality Improvement (PQI) project be completed by a radiologist for maintaining her certification.

Evidence Based Radiology & Technology Assessment

Evidence Based Radiology (EBR) is predominantly a bottom-up exercise where individual radiologists have to blend the best available evidence into their daily practice. However, there is an important role for the top-down approach: radiology managers have to implement guidelines and provide the infrastructure for efficiently accessing top-class evidence.

Technology Assessment (TA) is systematic evaluation of safety, efficacy, effectiveness and cost of healthcare interventions. As applied to radiology, TA involves measures of diagnostic accuracy (how well a test distinguishes disease from no-diseased state) and evaluation of diagnostic and therapeutic impact of the radiology investigation. EBR and TA are meant to discourage medical care based on inadequate evidence and to improve effectiveness of the money spent on healthcare.

In-view of the increasing public expectations of healthcare and increasing healthcare expenditures, there will be increased scrutiny of expensive, new technologies, hence the need for EBD and TA.

Patient & Staff Safety

Safety protocols have to be developed and implemented. It doesn't hurt to have visible validation of your safety standards, for instance, by accreditation to national and international monitoring agencies like the JCI. Continued training in utilisation of radiation - dose reduction techniques and maintenance of equipment with a view to ensuring patient and staff - safety has to become a way of life at the radiology centres. This is not just a demand of ethics and professionalism, but also safe - guards radiologists against litigation and promotes patient - confidence.

Futurology

A successful radiology facility owner or administrator has to be a futurologist too. Anticipating the technical advancements, the emerging socio-economic milieu and its impact on healthcare delivery systems and the forthcoming legal issues, ahead of others gives a competitive edge and yields economic gains. Healthcare delivery systems will become increasingly based on empanelment and insurance; this will demand quantifiable and reproducible gains from radiology investigations, in turn requiring QM, TA, EBR and standardisation of imaging methodology as discussed above.

On the technology front, we will increasingly move in the direction of image fusion (PET, CT, conventional MR and functional MR); holy grail of imaging is MR microscopy - since resolution in MRI is not limited by wavelength (image noise is the only limitation), MR microscopy is plausible; fusion of tractography with functional MR and MR microscopy can one day lead to real-time evaluation of processing in individual neural circuits. Secondly, there will be more and more of intra-operative imaging, so architects and hospital planners of today here to design ORs with options for intra-op imaging. Thirdly, PACS is going to be the back-bone of workflow. They say radiology will be in cyberspace in 10 years. So, a radiology facility has to have scope for expanding the computing and networking hardware.

As pointed above, radiologists are under pressure from all sides - trust of society in doctors is eroding, regulatory policies are in flux (PNDT is a prime example), economic pressures are rising and there is the fear of burnout as one maintains ethics and professionalism while meeting these challenges.

Paying attention to the issues discussed above and assimilation of the suggestions in daily practice will be beneficial to all radiology associates, facilitating their onward journey. We already have a strong and broad infrastructural base in radio-diagnosis in terms of strong presence of top international vendors, their personnel and inventories, chains of diagnostic centres, talented manpower, training institutions and quantum of work, some deft chiseling can transform what we have into the very best in the world.

drlovneesh@hotmail.com