Thursday, September 27, 2012

Mobile medical images challenge PACS administrators

The growing use of tablet devices and mobile phones by doctors for viewing medical images, pose a number of challenges for PACS administrators. Dr. David Hirschorn, is the director of radiology informatics at Staten Island University Hospital, N.Y. and a researcher in radiology informatics at Massachusetts General Hospital, Boston. He is also a member of the American College of Radiology IT and Informatics Committee, serving as a representative to FDA for mobile medical devices. He was a featured speaker at the Sept. 10 NY Medical Imaging Informatics symposium. PARCA E-News spoke to him, by cell phone (of course) to ask about these challenges.

Q. How did you become interested in medical imaging on mobile devices?
A. I’m a radiologist who researches  displays. For years I’ve looked at what we really need in order to read an x-ray or a CT scan. They make medical displays that are a lot more expensive than consumer displays.
I was interested in looking into when you need to use them, when you do not need to use them. Can you use consumer displays, and if so, when can you use them and how do you do it, and stay within the recommended guidelines and assure quality.

Mobile devices are a natural evolution of that research. Displays went from these huge, clunky CRTs, which I’m sure you remember, to gray scale LCD displays and then color LCDs, and then Apple comes out with the iPhone and the iPad and the iPad 3 now with 3 megapixels on a little device, and it begs the question, can you use these devices for medical images? Clearly there is a lot of convenience to the fact that these devices are mobile. So one of the first questions asked is can you put images on them, and is that OK? Can you render diagnosis off that? If so under what circumstances, and when should you not be doing that?

Q. Who is most likely to use medical imaging on mobile devices?

Dr. David Hirschorn 
A. No question the most common user of these devices for viewing medical images is going to be the referring doctor, the ordering physician. There are way more primary care physicians taking care of patients than radiologists. They already use their mobile devices to discuss medical images with their patients. Everyone (doctors) uses a mobile phone and it is not so inconvenient to walk around with an iPad, and the question is not if they are going to look at their patients’ information using these devices, but when should they use them.
In the case of using them to discuss a diagnosis with the patient there really isn’t too much to worry about.  Most of this use is not for primary diagnosis. It is to explain why the radiologist says it is pneumonia, or whatever, and the treating physician just wants to take a look at it to see what the radiologist has already diagnosed. There isn’t too much to worry about when used for secondary review. There is not too much concern about what device they are using and whether the device has been calibrated, and tested and all that kind of stuff. They are not making a treatment decision based on how it looks on that screen.

This is in contrast to those who are making clinical decisions based on how it looks. Certainly this includes the radiologist, who is making a primary diagnosis, but it is not limited to radiologists, it may be a cardiologist with a cardiac scan, but you have to be careful about overlap care. For example, the surgeon who is going to decide whether or not to operate based what they see. The radiologist is going to say what he sees, but the surgeon is also going to make additional judgments based on what she sees, and that I would argue is primary diagnosis and you do have to be careful (about using these devices for that). They are making a treatment decision on the basis of the image display.

Likewise, say residents are walking around the floor in the hospital with a tablet device and they decide they are going to feed the patient with a feeding tube and verify placement of the feeding tube on their own, without radiology, then that too would be a primary diagnosis and they need be sure they are using an adequate device to do that. That is not secondary review. So those are the types of people making decisions on the basis of what they see.

Q. What are the security issues and patient privacy issues that need to be considered?

A. Absolutely (security) is an issue. These devices are all over the place. Most of this (security) is taken care of by the software being used, meaning people tend not, and shouldn’t, e-mail patient data. They can but it is not convenient to do so, and that’s a good thing. You have to export the images, and save them and attach them to e-mail. That doesn’t mean that this doesn’t go on, it does, but it is less common.

What is more common, is a doctor belongs to a hospital and the hospital says here is our software you’re going to use to see your images. If you’re a doctor taking care of patients at our institution and you want to see the images, there is a portal on your device that will take you to all hospital images, not just radiology. And if it (access) is managed through those kinds of software systems those systems are not stupid. They don’t store anything locally on the device itself. Recognize that these mobile devices have a thin pipe network-wise going over broadband. I’ve seen hospitals with WiFi, which is much faster, but with ordinary broadband, you don’t want to download and store anything for the most part.

That is not what users want to do anyway; they just want to look at the patient’s data. They are not trying to copy it or export it. They are just trying to look at it. And as such, the software doesn’t save anything persistently on the device, it erases it, and when communicating, it is going over an encrypted protocol. It is not the same thing as say your contacts lists on your e-mail, where a slip of a keypad entry and somebody may get all my contacts. It doesn’t tend to be that way because nothing is stored locally. And particularly because it is centrally managed and it is not left up to users to decide on their own what kind of security they want to maintain, and centrally managed security doesn’t allow those kinds of things to happen.

Q. What are the top issues facing PACS administrators with regard managing mobile device imaging?

A. Clearly it is access. People are going to say they are trying to access images, and it isn’t working, I can’t see images on my device. And the PACS administrators are going to have to determine if this is an account issue or a platform issue. If your account isn’t active or it is expired or locked out, it doesn’t matter what device you are using. Or is it the device itself that is the problem, and they have to decide which devices they are going to support. Are they going to support iOS devices or Android, or both? They have to make that call. Part of that decision flows from what (viewing) software you choose, because not all software supports all platforms, so that is a buying decision.

One more point of interest is PACS administrators are often saddled with the task of ensuring quality on PACS monitors and so routine measurements are taken and documented so that when the Joint Commission comes knocking you can show that you’ve done your calibrations and you conform to standards. What is on the horizon, and people are just starting to use it, is that there is (calibration) software for mobile devices as well. As an example, let’s say the radiology department deploys iPads for the radiologists who are on call so the resident can ask them to look at something.

That all becomes the PACS administrator’s headache to make sure those iPads are working properly so the radiologist can look at the images off them. And there is software just coming onto market that allows them to do that as well. It works completely differently than that used for desktop displays because there is no built-in photometer to an iPad. Instead the software measures user responses, like a Tap Test, it asks the radiologist can you tap here? Can you see this? And takes measurements that way by human measurements but measurements nonetheless and it can fold that into the bookkeeping that they have to keep for all their displays.

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