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Progress and Complexity for the Next Century

¹ Department of Radiology, MZ-FND 216, P. O. Box 9657, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114-5244.

Received February 2, 2000; accepted after revision February 3, 2000.

 
Address correspondence to J. H. Thrall.

Introduction

Top Introduction

 
Unparalleled and unprecedented advances in radiology during the past decade are converging to create a theme that will dominate clinical, administrative, and research endeavors in the next decades: increasing complexity. This may appear to be a self-evident observation, but its implications to individual radiologists, departments of radiology, and medical institutions are enormous because their respective responses to increasing complexity will differentiate them and even define the quality and productivity of their efforts. Individuals and institutions that recognize the implications and opportunities associated with increasing complexity will flourish and will be at a competitive advantage over those who do not.?

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A compelling example of technologic convergence resulting in extraordinary complexity is the tectonic shift of radiology to paperless and filmless systems. The first important infrastructure component of this shift occurred more than 25 years ago with the development of automated computer-based dictation systems. In the beginning, these were stand-alone systems. They added great value to the radiologic process by making the reporting process more efficient.

The second important component of the digital revolution was the Radiological Information System (RIS). During the past 15 years, these systems have been widely deployed and provide the administrative infrastructure for departmental operations, including patient scheduling and billing, department management, and archiving of radiology reports. The RIS is typically a stand-alone system either interfaced to a hospital information system or imbedded as a component of the hospital information system.

The third and, in many ways, most challenging component in the digital revolution is the picture archiving and communication system (PACS). These systems allow the electronic management of radiologic images, an ever-increasing percentage of which are in digital form.

Each of the foregoing systems taken alone can be considered a major advance, but it is only through their effective integration that the real operational goals of contemporary radiology can be met. It is precisely in achieving robust integration that the issue of complexity must be addressed. One way of envisioning the goal of integrating these complex systems is to imagine an "electronic round-trip" wherein a physician enters an electronic request for an imaging study from his or her desktop computer and receives both the report and the images back on the same desktop computer without the need to repeat the entry of patient demographic or study data at any point in the process. This requires an unbroken chain of information transfer from the physician's desktop to the hospital information system, RIS, imaging device, PACS, and transcription system, and then back through the RIS, PACS, and hospital information system to the physician's desktop.

At present this chain of information transfer has several missing links or discontinuities. For example, equipment vendors are only beginning to enable the automated transfer of study information from the RIS to imaging devices such as MR and CT scanners. Likewise, links between the PACS and the RIS remain problematic, as do connections between transcription systems and the PACS.

The punch line is that the acquisition and implementation of any of the component systems is far easier and less complex than the achievement of full integrated function between systems. In fact, at the turn of the millennium, no institution has achieved complete connectivity of all components. In some sense, the challenge of complexity in bringing the whole process together amounts to a raising of the bar. Departments and institutions that are successful will have quality, cost, productivity, and patient and provider satisfaction advantages compared with institutions that do not meet the challenge.

An important example of increasing complexity raising the bar for clinical practice is the rapid transition from the era of cross-sectional radiology to the era of three-dimensional (3D) radiology. Three-dimensional imaging is being driven by two dominant factors. First, there are applications in MR imaging and CT that are simply best viewed in the context of one kind of 3D presentation or another. Examples include MR angiography and CT angiography, a number of musculoskeletal applications, and gastrointestinal applications such as virtual colonography. A second driving factor is the sheer amount of data generated by contemporary imaging devices and the practical benefit of being able to condense dozens or even hundreds of two-dimensional cross-sectional images into a smaller number of 3D images.

The complexities associated with 3D imaging will challenge departments of radiology. Software programs for 3D applications are not yet developed as turnkey systems. Substantial additional training and experience will be required whether physicians or technologists perform the 3D transformations. The logistics of image handling are also challenging. Large data sets must be moved to dedicated 3D processing workstations. Processed images need to be passed back to PACS files for archiving and general access over departmental and hospital networks.

The potential power and value of 3D imaging will be foregone in many radiology departments because of the complexities of acquiring new rendering software, training personnel, and designing integrated handling systems for the large data sets involved.

These examples are simply two from a very daunting list. Common themes include the relentless development of new technology that must be assimilated into radiology departments, the need for ever higher levels of true systems integration to create connectivity and eliminate bottlenecks and lost productivity, and the need for ever higher levels of training and education for both radiologists and allied health workers. New job categories or more reliance on outsourcing will be required to support the increasingly complex infrastructure in radiology departments.

The future of radiology is incredibly bright, but radiologists must recognize increasing complexity as one of their major challenges in the next decades and must develop explicit strategies for dealing with it.

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Thrall, J. H. Search for Related Content PubMed PubMed Citation Articles by Thrall, J. H. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?