Posts Tagged ‘RSNA’

Telemedicine Part 1: TeleRadiology as the growth medium of Precision Medicine

Sanjay Joshi

CTO, Healthcare & Life-Sciences at EMC
Sanjay Joshi is the Isilon CTO of Healthcare and Life Sciences at the EMC Emerging Technologies Division. Based in Seattle, Sanjay's 28+ year career has spanned the entire gamut of life-sciences and healthcare from clinical and biotechnology research to healthcare informatics to medical devices. His current focus is a systems view of Healthcare, Genomics and Proteomics for infrastructures and informatics. Recent experience has included information and instrument systems in Electronic Medical Records; Proteomics and Flow Cytometry; FDA and HIPAA validations; Lab Information Management Systems (LIMS); Translational Genomics research and Imaging. Sanjay holds a patent in multi-dimensional flow cytometry analytics. He began his career developing and building X-Ray machines. Sanjay was the recipient of a National Institutes of Health (NIH) Small Business Innovation Research (SBIR) grant and has been a consultant or co-Principal-Investigator on several NIH grants. He is actively involved in non-profit biotech networking and educational organizations in the Seattle area and beyond. Sanjay holds a Master of Biomedical Engineering from the University of New South Wales, Sydney and a Bachelor of Instrumentation Technology from Bangalore University. He has completed several medical school and PhD level courses.

Real “health care” happens when telemedicine is closely joined to a connected-care delivery model that has prevention and continuity-of-care at its core. This model has been defined well, but only sparsely adopted. As John Hockenberry, host of the morning show “The Takeaway” on National Public Radio, eloquently puts it: “health is not episodic.” We need a continuous care system.

Telemedicine makes it possible for you to see a specialist like me without driving hundreds of miles

Image source: Chest. 2013,143 (2):295-295. doi:10.1378/chest.143.2.295

How do we get the “right care to the right patient at the right time”? Schleidgen et al define Precision Medicine also known as Personalized Medicine (1) as seeking “to improve stratification and timing of health care by utilizing biological information and biomarkers on the level of molecular disease pathways, genetics, proteomics as well as metabolomics.” Precision Medicine (2) is an orthogonal, multimodal view of the patient from her/his cells to pathways to organs to health and disease. There are several devices and transducers that would catalyze telemedicine: Radiology, Pathology, and Wearables. I will focus on Radiology for this part of my three-part series, since all of these modalities use multi-spectral imaging.

Where first?
The world is still mostly rural. According to World Bank statistics, 19% of the USA is rural, but the worldwide average is about 30% which is a spectrum from 0% rural (Hong Kong) to 74% rural (Afghanistan). With the recent consolidations (since 2010 in the US) of hospitals into larger organizations (3), it is this 30% to 70% of the world with sparse network connectivity that needs telemedicine sooner than the well-off “worried well” folks who live in dense urban areas with close access to healthcare. China has the world’s largest number of hospitals at around 60,000 followed by India at around 15,000. The US tally is approximately 5,700 hospitals. The counter-argument to the rural needs in the US is the risk of reduction of physician numbers (4), the growing numbers of the urban poor and the elderly. Then there is the plight of poor health amongst the world’s millions of refugees who are usually stuck in no-mans-lands, fleeing conflicts that never seem to wane. All these use-cases are valid, but need prioritization.

Connected Health and the “Saver App”
Many a fortune has been made by devising and selling “killer apps” on mobile platforms. In healthcare what we need is a “saver app.” Using the pyscho-social keys to the success of these “sticky” technologies, Dr. Joseph C. Kvedar succinctly builds the case for connected health in his recent book “The Internet of Healthy Things” with three strategies and three tactics:

Strategies: (1) Make It about Life; (2) Make It Personal; and (3) Reinforce Social Connections.

Tactics: (1) Employ Messaging; (2) Use Unpredictable Rewards; and (3) Use the Sentinel Effect.

Dr. Kvedar calls this “digital therapies.”

The Vendor Neutral Archive (VNA) and Virtual Radiology
The Western Roentgen Society, a predecessor of the Radiological Society of North America (RSNA), was founded in 1915 in St. Louis, Missouri (soon after the invention of the X-Ray tube in Bavaria in 1895). An interactive timeline of Radiology events can be seen here. Innovations in Radiology have always accelerated the innovations in healthcare.

The Radiology value chain is in its images and clinical reporting, as summarized in the diagram below (5):

Radiology value chain

To scale this value-chain for telemedicine, we need much larger adoption of VNA, which is an “Enterprise Class” data management system. A VNA consolidates multiple Imaging Departments into:

  • a master directory,
  • associated storage and
  • lifecycle management of data

The difference between PACS (Picture Archiving and Communications System) (6) and VNA is the Image Display and the Image Manager layers respectively.

The Image Display layer is a PACS Vendor or a Cloud based “image program”. All Admit, Discharge and Transfer (ADT) information must reside with the image. This means DICOM standards and HL7 X.12N interoperability (using service protocols like FHIR) are critical. The Image Manager for VNA is the “storage layer of images”, either local or cloud based. For telemedicine to be successful, VNA must “scale-out” exponentially and in a distributed manner within a privacy and security context.

VNA’s largest players (alphabetically) are: Agfa, CareStream, FujiFilm (TeraMedica), IBM (Merge), Perceptive Software (Acuo), Philips and Siemens. The merger of NightHawk Radiology with vRad which was then acquired by MedNax and IBM’s acquisition of Merge Healthcare (in Aug 2015) are important landmarks in this trend.

One of the most interesting journal articles in 2015 was on “Imaging Genomics” (or Radiomics) of glioblastoma, a brain cancer. By bidirectionally linking imaging features to the underlying molecular features, the authors (7) have created a new field of non-invasive genomic biomarkers.

Imagine this “virtual connected hive” of patients on one side and physicians, radiologists and pathologists on the other, constantly monitoring and improving the care of a population in health and disease at the individual and personal level. Telemedicine needs to be the anchor architecture for Precision Medicine. Without Telemedicine (and VNA), there is no Precision Medicine.

Postscript: Telepresence in mythology
Let me end this tale of distance and care with a little echo from my namesake, Sanjaya, who is mentioned in the first chapter of the first verse of the Bhagvad Gita (literally translated as the “Song of the Lord”) – an existential dialog between the warrior Arjuna and his charioteer, Krishna. The Gita, as it is commonly known, is set within the longest Big Data poem with over 100,000 verses (and 1.8 million words), the Mahabharata, estimated to be first written around 400 BCE.

Dhritarashtra, the blind king, starts this great book-within-book by enquiring: “O Sanjaya, what did my sons and the sons of Pandu decide about battle after assembling at the holy land of righteousness Kurukshetra?”

Sanjaya starts the Gita by peering into the great yonder. He is bestowed with the divine gift of seeing events afar (divya-drishti); he is the king’s tele-vision – and Dhritarashtra’s advisor and charioteer (just like Krishna in the Gita). The other great religions and mythologies also mention telepresence in their seminal books.

My tagline for the “trickle down” in technology innovation flow is “from Defense to Life Sciences to Pornography to Finance to Commerce to Healthcare.” One interpretation of the Mahabharata is that it did not have any gods – all miracles were added later. Perhaps we have now reached the pivot point for telepresence which has happened in war to “trickle down” into population scale healthcare without divine intervention or miracles!

References:

  1. Schleidgen et al, “What is personalized medicine: sharpening a vague term based on a systematic literature review”, BMC Medical Ethics, Dec 2013, 14:55
  2. “Toward Precision Medicine”, Natl. Acad. Press, June 2012
  3. McCue MJ, et al, “Hospital Acquisitions Before Healthcare Reform”, Journal of Healthcare Management, 2015 May-Jun; 60(3):186-203.
  4. Petterson SM, et al, “Estimating the residency expansion required to avoid projected primary care physician shortages by 2035”, Annals of Family Medicine 2015 Mar; 13(2):107-14. doi: 10.1370/afm.1760
  5. Enzmann DR, “Radiology’s Value Chain”, Radiology: Volume 263: Number 1, April 2012, pp 243-252
  6. Huang HK, “PACS and Imaging Informatics: Basic Principles and Applications”, Wiley-Blackwell; 2 edition (January 12, 2010)
  7. Moton S, et al, “Imaging genomics of glioblastoma: biology, biomarkers, and breakthroughs”, Topics in Magnetic Resonance Imaging. 2015

 

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The Radiological Society of North America (RSNA) Annual Meeting 2015 — Summary Report

Sanjay Joshi

CTO, Healthcare & Life-Sciences at EMC
Sanjay Joshi is the Isilon CTO of Healthcare and Life Sciences at the EMC Emerging Technologies Division. Based in Seattle, Sanjay's 28+ year career has spanned the entire gamut of life-sciences and healthcare from clinical and biotechnology research to healthcare informatics to medical devices. His current focus is a systems view of Healthcare, Genomics and Proteomics for infrastructures and informatics. Recent experience has included information and instrument systems in Electronic Medical Records; Proteomics and Flow Cytometry; FDA and HIPAA validations; Lab Information Management Systems (LIMS); Translational Genomics research and Imaging. Sanjay holds a patent in multi-dimensional flow cytometry analytics. He began his career developing and building X-Ray machines. Sanjay was the recipient of a National Institutes of Health (NIH) Small Business Innovation Research (SBIR) grant and has been a consultant or co-Principal-Investigator on several NIH grants. He is actively involved in non-profit biotech networking and educational organizations in the Seattle area and beyond. Sanjay holds a Master of Biomedical Engineering from the University of New South Wales, Sydney and a Bachelor of Instrumentation Technology from Bangalore University. He has completed several medical school and PhD level courses.

Wilhelm Konrad Roentgen, Professor of Physics in Worzburg, Bavaria discovered X-Rays in 1895 by observing and deducing an accidental exposure of energy from his early design cathode ray tube onto a photographic plate. The first X-Ray was of his wife’s hand, shown below. X-Rays are one of the earliest great discoveries of the post-Renaissance age, even before E=mc2. Radiological Society of North America (RSNA) has been the definitive gathering place for the future of Radiology and Healthcare technology for as long as I can remember. X-Rays and its cousin spectra drive most of the new innovations in instrumentation, process and informatics.

XrayThe Western Roentgen Society, a predecessor of the RSNA, was founded in 1915 in St. Louis, Missouri. RSNA celebrated its centennial last year in Chicago (the anchor city for the conference for a long time). An interactive timeline of RSNA and Radiology events can be seen here.

I broke my almost 18-year attendance hiatus after my RSNA Associate membership acceptance this year; I started my career building X-Ray machines many, many moons ago and have worked in most Radiology modalities.

Technology Highlights:

The scale of the conference was impressive, as has always been. The Technical and Exhibition Hall was massive at the McCormick Place Conference Center in Chicago. With about 670 exhibitors (105 new exhibitors) and the “who’s who” anchors like Bayer, Canon, CareStream, FUJIFILM, GE, Hitachi, Hologic, McKesson, Philips, Samsung, Shimadzu, Siemens, Terarecon and Toshiba this year’s technology innovation highlights were:

  • GE 1.5 Tesla and 3 Tesla MRI (Magnetic Resonance Imaging) instrument with Total Digital Imaging (TDI) as well as CardioVascular Ultrasound systems with HDlive.
  • Siemens 3D Advanced Visualization software, Cloud-based imaging network and xSPECT (Single Proton Emission Computed Tomography) for bone scans along with the combination of MRI-PET and PET-CT modalities.
  • Virtual Reality (True3D), 3D printing, Human Connectome, Machine Learning and Deep Learning.
  • RSNA Image Share, a Provider and Patient service.
  • The maturing of Vendor Neutral Archives (VNA).

Plenary sessions:

On Monday November 30th, the “New Horizons Lecture: Redefining Innovation” was delivered by Jeffrey R. Immelt, Chairman and CEO of GE. Mr. Immelt made the point that GE was both in the instrumentation innovator (US$20B) and payor (US$2.5B) revenue streams in healthcare. He emphasized that improving the ecosystem (consumerism + access, chronic disease outcomes, lower cost and behavior changes) as well as sustaining innovation (neural MRI, decision support, image guided interventions, automated image analysis and productivity) were its guiding principles. Precision Medicine, integration of Radiology with Pathology, cell therapy using Bioprocessing, mobile technologies at global scale and analytics were the central innovation themes for GE.

On Tuesday, December 1st, Dr. James H. Thrall, Chairman Emeritus, Department of Radiology at Massachusetts General Hospital, delivered the “Annual Oration in Diagnostic Radiology: Trends and Developments Shaping the Future of Radiology”. He outlined three themes: imaging technologies, infrastructure and information/communications systems, and the application of the imaging correlates of precision medicine. Dr. Thrall presented a Venn diagram of all imaging modalities. The various inter-modal intersection sets were highlighted with specific mention of PET-CT-MRI and the work of Dr. Ge Wang and Omni-Tomography was highlighted as shown in the figure below:

Omni Tomography

Of particular note to me was the official entry of “Precision Medicine” into the RSNA lexicon. This is the first year I have heard of the term “RadioGenomics” and “RadiOmics” in a major conference (first mentioned by Andreassen et al in 2002). Dr. Thrall made it a point to mention shorter acquisition times and lower radiation dosage to the patient.

Dr. Ronald Arenson, RSNA President, introduced both plenary speakers.

Academic Sessions:

My focus for the 2015 Academic sessions was Informatics. Here are the condensed highlights:

Dr. Charles Kahn (U Penn) and Dr. Bradley Erickson (Mayo) led the inaugural “Year in Review” for Imaging Informatics. This session was jointly sponsored by RSNA, AMIA (American Medical Informatics Association) and SIIM (Society for Imaging Informatics in Medicine). The format was a dense, rapid-fire summary of key topics for 2015 as well as the seminal journal articles on various topics, which were the foci of other informatics sessions:

“The Text Information Extraction for Radiology Reporting” session presented techniques using NLP, Machine Learning and Deep Learning. A majority of radiologists would like to see structured reporting. The tools mentioned were OpenNLP, Mallet, cTAKES, eHOST, VINCI ChartReview and NCBO Annotator.

One of the more useful “hands-on” sessions that I attended was “Radio-Genomic Research: Accessing Clinical Imaging-Genomics-Pathology Data from Public Archives-The Cancer Imaging Archive” led by Dr. C. Carl Jaffe and Dr. Fred W. Prior. The Cancer Genome Atlas (TCGA) data portal is well known in the Genomics. The NIH has now created The Cancer Image Archive (TCIA) which has specific deidentified images for integrating Radiology with Genomics.

There was an entire morning session devoted to “Digital Information Security and Medical Imaging Equipment” which covered the instrumentation layers, protocols and regulations in some detail. It is interesting to note that Radiology Imaging client applications are still using OSx as the primary platform, with some “hands-on” sessions for DICOM not using other OSes at all. It is time for a web service based imaging application to come to the fore.

I strongly believe that integrating (and interoperating with) Radiology and Pathology phenotypic moieties into Genomics knowledge will be the real catalyst for the adoption of Genomics as an early clinical test (which is getting more complex by the month). Oh, and let’s not forget Proteomics. If multi-modal Radiology becomes reality soon (especially PET-CT-MRI), using biomarker-guided imaging, the data generated and the analytics required both grow exponentially. We are getting to that unified “Healthcare Data Lake” as shown below:

EMC Healthcare

RSNA is now one of the top two academic conferences in the United States (and maybe worldwide) with a 2014 attendance of about 57,000. The 2015 attendance dropped, with registered attendants numbering about 48,000 (as of this writing). Here is hoping for more radiologists, technologists, innovators and patient advocates for this year’s RSNA!

Stay warm and healthy!

 Author’s notes: The opinions expressed herein are my own and not necessarily those of EMC. Hyperlinks are embedded within specific words or phrases. Please contact me if you need details on any of the above topics.

 

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