Radiology Technology Comes with Pros, Cons on Arkansas Medical News Inc.

Radiology Technology Comes with Pros, Cons

By: STEVE BRAWNER

Dr. Kenney along with Dr. Kedar Jambhekar, assistant professor, who is reading a scan.

Challenges Accompany Increased Clarity, Portability

Philip J. Kenney, MD, chairman of the University of Arkansas for Medical Sciences Department of Radiology, pauses in the room that once housed the hospital’s film processing unit for x-rays.

It looks like a scene from a movie where someone returns from a journey to discover that all the humans have mysteriously disappeared. The furniture is dated and unused. Forgotten boxes rest upon a table. An analog clock that looks like it was bought in the 1970s is still on daylight savings time.

The room has been abandoned because UAMS, like other hospitals around the state, has found other ways to see inside patients’ bodies. UAMS now has seven MRIs and five CT scanners. Baptist Health went completely filmless in 2005 and connected its facilities around the state with a gigabit of bandwidth so images could be transmitted electronically, according to David Fox, assistant vice president for clinical services. According to Sissy Pederson, director of imaging services at Washington Regional Medical Center, her hospital was built in 2002 to be digital right out of the gate. The hospital says it is among the top 1 percent in the nation in its conversion to electronic medical records.

The benefits of modern radiology are impossible to ignore, and no one suggests going back to the days when the medical community’s options included only ghostly x-rays and exploratory surgery. But the changes brought by that new technology are forcing radiologists to answer difficult questions.

Chief among them are the risks of ionizing radiation used in CT scans. Today’s machines are capable of slicing the body into multiple layers and putting the images on a screen, but each scan exposes patients to more radiation, and the effects are cumulative. Making the dilemma even more difficult is the fact that the more radiation used, the better the scan, so medical providers must choose between what a patient needs right now and what might cause harm in the future.

John Meadors, MD, co-medical director of the radiology department at Radiology Associates in Benton, worries that his profession is overutilizing the technology. “In theory, we’re increasing the risk of Americans getting cancer just from probably ordering likely too many tests,” he said.

Often that occurs because radiologists merely are trying to use the best technology to serve the patients. But Meadors said the incentives of the current medical system contribute to unnecessary scans. Providers fear being sued if they don’t order a scan for what seems like a simple headache but turns out to be a tumor. Moreover, CT scanners aren’t cheap, and the only way to pay for them is by using them. A new one costs

$1-$2 million, and while monthly payments vary wildly, he guessed they can equal $30-$40,000. “For most of these high-end pieces of equipment,” he said, “you’re looking to have to do a minimum of say five to seven patients a day to break even. … Now once you reach that threshold each day and you scan patients beyond that, well then, that’s profit.”

Meadors looks forward to the day when a national registry will make it easier to keep track of a patient’s radiation history so providers don’t order more scans than necessary for new patients who may already have been tested numerous times. “Patients dance around from hospital to hospital like jitterbugs in this state,” he said.

Despite the risks, there’s no doubt that CT scanners are sometimes the recommended option over other exploratory devices such as MRIs, which don’t have a corresponding radiation risk. CT scanners are much faster than MRIs. UAMS’ Kinney points out that the 64-slice CT scanner in his hospital’s emergency room can do a full-body scan in three minutes while an MRI would take 45 minutes – an important distinction when a patient is bleeding internally and the doctor doesn’t know why. For children, CT scanners are often the only option because there is no way a child will sit still long enough to be scanned by an MRI.

The key is not to end the risk of radiation exposure but to minimize it through careful monitoring of the machines, staff dedicated to addressing the problem, and protocols that prevent technicians from exposing patients to amounts that are more than what is known in the business as ALARA – as low as reasonably achievable.

“It’s a concern, and we have a pretty big program for controlling doses in kids and making sure we stay within or below guidelines when we do CT scans on children,” said Charles Glasier, MD, director of radiology at Arkansas Children’s Hospital.

While not minimizing the radiation hazards, providers point out that CT scans reduce risks associated with other exploratory options, such as the anesthesia and exposure to infections associated with surgery. Glasier pointed out that humans are exposed to a certain amount of radiation just by being alive. In fact, people are exposed to increased radiation from the sun by flying in a plane or living in Denver. “Properly performed CT scans that are kept to reasonable dose levels, a lot of the risk is theoretical as far as the levels that are done in most diagnostic settings,” Glasier said.

Accompanying the scanning technology is the ability to transmit it. Hospitals contacted for the story have the ability to view scans instantly from different parts of the hospital or parts of the state with no time required for downloading.

But that technology also brings with it challenges pertaining to patient confidentially that didn’t exist when x-ray scans were kept under lock and key. And as more and more information is stored or transmitted on highly portable devices such as smart phones and iPads, a careless moment could lead to a major HIPPA violation.

“People lose their iPhone all the time,” UAMS’ Kinney said. “What if you’re using your iPhone to receive information about patients, and you have a bunch of patient information stored on there and you lose it? Essentially, that’s a federal violation. That’s a crime, essentially.”

Thanks to the new technology, there is now less face to face interaction between a treating physician and radiologist, and some would call that a bad thing. Kinney compared the new way of practicing radiology to the job of an NFL offensive coordinator, who in the past called plays from the sideline but now typically sits in a booth high over the field where he can see all that is happening and then communicates with the head coach and quarterback using a headset.

The upside to all of this electronic communication of course, is the same as it is in every industry – it’s effective and efficient. Being able to transmit scans across a hospital as big as UAMS saves specialists and radiologists an enormous amount of time just in walking between offices – time that can be spent treating patients. Going back to the past is inconceivable despite the past’s interpersonal advantages.

So just how portable will this new technology become? While radiologists and doctors can use the devices to communicate with each other, neither Kinney nor his associate professor of radiology, Rudy Van Hemert, MD, foresee a time soon when physicians and radiologists can simply carry an iPad to view their scans.

Current screen resolutions simply don’t have the definition to see certain anomalies, and though technology is ever changing, one thing that won’t change, at least for a while, is size: Tablets and smart phones simply aren’t as big as the multiple monitors radiologists currently use. Moreover, reading scans typically requires sitting in a darkened room in a comfortable chair – not walking around in a hospital room carrying an iPad.

“Radiologists actually synthesize the images into a concept of what’s going on with the patient,” Kinney said. “It’s a little bit of a complex intellectual exercise. It’s not just looking at a picture and saying, ‘Well, there’s that.’”