| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Centennial Sounding Board |
1 Department of Diagnostic Radiology, Yale University School of Medicine, P. O. Box 208042, New Haven, CT 06520.
Received December 17, 1999;
accepted after revision January 4, 2000.
Address correspondence to B. L. McClennan.
Introduction
 Top Introduction References |
|---|
Awash in the glow of Roentgen's new light, medical practitioners developed the fluoroscopic screen, flat plates, then films in negative (transparent) format to be displayed on a lighted viewbox. Now the glow of Roentgen's tube has been concentrated and magnified to floodlight proportions by the development of powerful, high-resolution workstations and digital transmission of radiologic images. Yale University's Department of Radiology is situated in the center of this brightly lit terrain using the most advanced digital technology in its continuing attempts to advance the clinical and technical frontiers at Yale New Haven Hospital.
Although the past is a proven prologue for the future, the present is the best predictor for what lies immediately ahead. Our department accepts today's expectation for improved communication, increased precision, and timeliness of diagnoses (and dictated and signed reports) 24 hours a day, 365 days a year; demands that have literally redefined work at an academic department of radiology. This new mode of practice has contributed to the blurring of the boundaries between subspecialities—for example, the combination of gastrointestinal and genitourinary services and multidisciplinary approaches to complex medical conditions. Discussions are moving to action plans for development of centers of excellence (also known as product service lines) for heart disease, vascular disease, particularly rare disorders like hereditary hemorrhagic telangiectasia, and cancer.
The success or failure of these efforts will determine the shape and technical administration of radiology departments at teaching hospitals here and elsewhere. All this growth is occurring in spite of declining reimbursement, burdensome billing and compliance regulations, and the proliferation of expensive technologies in response to continuing medical breakthrough discoveries and continuing public demand for faster, more accurate, and less invasive clinical options.
Although the practice of radiology and the structure of departments at Yale are undergoing metamorphosis, the process and flow of work are morphing as well. Radiologic support systems are taking on a revolutionary new appearance. The film library of today is turning into a high-capacity multitier digital storage archive with the latest generation DLT (digital linear tape) or equivalent storage media. Study servers with fast and reliable RAID (redundant array of independent/inexpensive discs) storage devices replace cumbersome file-room shelves, stuffed to overflowing with paper X-ray jackets. The hospital-wide computer network joins with our department's intranet and with the medical school's computer network, all of which are interconnected using traditional ethernet, Internet, and the newest Fibre Channel and next-generation Internet. This network is in evidence anywhere one walks.
These changes in work flow and process, considered radical only a few years ago, were made possible with the same computer technology and graphics that gave us "Star Wars" and "Toy Story 2." A recent glimpse at the Yale University Weekly Bulletin shows that researchers in the faculty of engineering in conjunction with those at Rice University have hugely increased computer storage capacity using a molecular memory system based on a single molecule. This work, presented at the International Electron Devices meeting in Washington, DC, in December 1999, incorporated in a single-molecule memory more ability to store information than that which exists in conventional silicone memory chips and claims a life expectancy 1 million times longer. Soon, passing down the hallway, we may find the section of cellular and molecular imaging and computing not far from our nuclear medicine section and our molecular memory bank.
Our PACS (picture archiving and communication systems) model, which has been undergoing development for the past 3 years, is one third to one half the way to complete installation throughout the department and has already bred an intense dependency and demand from both radiologists and referring physicians. This appetite for the image and consultative report on-line and in real-time is voracious. Although the biggest and, perhaps, most costly phase of PACS implementation is yet to come, as images and information are disseminated throughout our health care enterprise via modems or cables to personal computers, the commitment and, in fact, the financing to do this are in place. A new acronym at Yale, CIIMS (Clinical Imaging and Information Management Systems) has all but replaced the old acronym, PACS.
Our department is the leader of and the general contractor for the concept, creation, and implementation phases and the broker for the dissemination of these important technologic tools so necessary for the fulfillment of our clinical mission. The number of patients, procedures, films, images, biopsies, or all the above, which are our work, may still define what we get paid for, but work-flow changes and efficiencies are defining how much we earn from our work. Harnessing the power of the World Wide Web to deliver a real-time consultation to a referring physician on-line via e-mail using the Internet has made communication via fax or post almost obsolete for carrying the same information.
As the substance of a workday (or night!) has changed, so has the structure of our department. Although you still find standard subspecialty sections such as pediatric imaging and neuroradiology, which have integrated all techniques for imaging and intervention, completely new sections are also forming. For example, emergency radiology now includes full-time diagnostic radiology now includes full-time diagnostic radiology specialists, conversant with the problems specific to this newly centralized mode of medical care delivery. The comprehensiveness of the emergency department's night-time service resembles that available during daylight hours. Improvement in satisfaction at our interface with emergency medicine, orthopedics, trauma surgery, obstetrics and gynecology, and pediatrics, as they converge in the emergency department, is palpable.
Further dissection of our own departmental structure reveals a series of clinical support and experimental laboratories, including a hot laboratory for radiopharmaceuticals, a dog laboratory for experimental research, a PACS laboratory, a three-dimensional laboratory, and more than one chemistry laboratory. Centers with and those without walls or buildings include the Magnetic Resonance Center, the PET Center, the Cerebrovascular Center, and a host of programs, some not so new, in women's imaging, imaging-guided neurosurgery, and hereditary hemorrhagic telangiectasia.
The quantity of our work, however defined, has increased and there are growing backlogs of demand. The old days of screening with chest radiographs or photofluorograms for tuberculosis or pneumonoconiosis may be remembered by some with nostalgia. Today, we are asked to screen for colonic cancer and lung cancer with cross-sectional imaging and for breast cancer with new digital detectors.
It is no surprise that all this costs money and consumes resources—energy, time, people, and space. Some of these efforts are integral to the modern diagnostic radiology department in the 21st century; others, such as multidisciplinary and interdisciplinary research efforts in vascular disease and oncology, are cooperative efforts with other departments.
Where we practice is also changing as telemedicine and teleradiology allow us to work effectively at a distance from patients and imaging devices. Our department is completing renovation and expansion to accommodate the patient and physician needs of tomorrow while remaining cognizant of the needs of the hospital, the health care system, the medical school, and the faculty practice plan today.
The demand for radiologic services is steadily increasing. As the less severely ill are more frequently treated outside the hospital setting, our average hospitalized patients increase in age and spend more time in intensive care units. The number of comorbid conditions that accompany today's typical hospitalized patient has increased. The ability to prolong lives has increased the medical complexity of treating our outpatients as well, adding to the volume of procedures and tests performed (e.g., a 45% increase in CT scan volume in the past 4 years at Yale).
The number of minimally invasive procedures using needles, catheters, guidewires and other delivery devices, or ports is also on the rise. Whatever the radiology pie chart looked like last century, this century's pie chart shows a vascular and interventional radiology piece much larger—and growing larger still.
The content of the imaging piece of the pie has changed dramatically. The advent and proliferation of multidetector multislice helical CT scanners have rushed us to the era of screening by giving us the ability to detect such conditions as colonic polyps and pulmonary emboli. In nuclear medicine we are influencing the oncologic imaging and staging process for several common malignancies with positron emission tomography and single-photon emission computed tomography.
Our constant companions on this journey through the forest of changes in the structure, form, and function of an academic radiology department are our missions of teaching and research. Pages of this great journal are and will continue to be filled with the stories of success in advancing the knowledge and skills of our specialty. We must find ways to continue to effectively teach these stories to our students and trainees, while still recognizing the obligations for billing and compliance, continued assessment of competence, recertification, credentialing, and privileging. At the end of his century Mark Twain [2] said:
If I were required to guess off-hand, and without collusion with higher minds, what is the bottom cause of the amazing material and intellectual advancement of the last fifty years, I should guess that it was the modern-born and previously non-existent disposition on the part of men to believe that a new idea can have value.
The discovery of the X ray proved him correct. The value of the digital revolution will be determined by our ability to adapt our modes of practice and management of our time to the new challenges and the new constraints imposed by this new technology and the new culture it has brought. Our responses will surely change the structure, form, and face of our work as radiologists but, just as surely, will offer us new opportunities to contribute to the well-being of our patients and new sources of personal and professional satisfaction.
|
TopIntroductionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
