During morning rounds, a physician visits with every patient, not once coming upon an empty room. A radiologist on the West Coast interacts on a study with a colleague on the East Coast—in real time. In a major metropolitan emergency department (ED), the trauma team organizes appropriate treatment for a patient—before the ambulance even arrives at the hospital.

An episode of The Twilight Zone? Hardly. In fact, before long, scenes like this will be taking place across the country. Driven by a new breed of wireless technology and the creative minds pushing it to its limits, the future holds great things for physicians and patients alike.

Wireless Wonderland

In a perfectly wireless world, information would not be limited by distance. Using a personal digital assistant (PDA), paramedics record a critical patient's vital signs as they load the patient into an ambulance equipped with a live, bidirectional video link to the hospital.

While the patient is en route to the ED, the trauma team at the facility could prepare as necessary. If surgery or radiology is required, available rooms would be noted, and appropriate staff members would be alerted automatically. As the vehicle backs up to the ED, the data would transfer to the hospital's wireless system, transferring all information into the patient's file.

Once in the care of hospital staff, the patient would be outfitted with a wristband that not only monitors his or her location, but also alerts clinicians of possible drug interactions.

Individuals like Evan Bontemps, president and CEO of Pannevera Inc (Newmarket, NH), are helping bring this dream closer to reality.

"We are developing long-range RFID Web-based appliances," he says. "This provides the ability to automatically locate any asset within the hospital, be it the patient or mobile electronics."

Radio frequency identification (RFID) technology makes it possible for the capture and transfer of data between a reader (or readers) and multiple tags through induction. Because communication between the reader and a tag is automatic, it provides a highly efficient way to track objects—or people—by simply adorning them with an RFID device.

Because all data is stored on the network, not on the tag, the systems are more affordable than in previous years. Also, benefits go beyond just identifying the physical location of a specific piece of equipment. For instance, RFID asset tags can indicate if the equipment is operational and if it is due for servicing.

"Based on the data accessed via the tag attached to the device, [staff members] also could know exactly what the machine is capable of doing," Bontemps says. "For example, it would indicate whether a pump is specifically for blood transfusions or for saline solutions."

The solution is currently undergoing clinical trials, and Bontemps expects that it will be available commercially in September.

A Brave New World

If employee identification (ID) badges bear RFID tags, the network could monitor their locations and interactions with patients and equipment. The network would continuously gather information from all tags—comparing data and sounding alarms when programmed. One example is equipment, such as portable ultrasound devices, nearing an exit unaccompanied by an employee badge. Exactly what would happen in such a case depends on the preferences of the facility's tech team, but possible responses could range from alerting security to the automatic locking of all doors and elevators.

Maintaining all data on the network makes the tags less expensive and makes the data they fetch more secure. It also provides a way to monitor patient information more closely than ever before. Ideally, a nurse would enter the patient's room with a wireless device, such as a PDA or tablet PC. As he or she approaches the patient, the network reconciles the information from the nurse's ID badge, notes his or her privileges for the patient, and all associated records would load automatically to his or her wireless device.

Ease of scheduling would improve as radiology-department heads effortlessly track exactly when and how often their imaging systems are put to work.

And last, but certainly not least, physicians also would realize benefits as they make rounds. A radiologist, for example, would know not only when the patient's exam has been completed, but also whether the patient was actually back in his or her room.

Physicians also would be able to receive study images anywhere in the hospital.

"The beauty of this is that the radiologist can start formulating thoughts on how he or she can begin to treat the patient immediately," Bontemps says. "As opposed to waiting for images, the information will be available on his or her tablet PC, wherever the radiologist is."

Prefer Paper?

Bontemps envisions a time when paper files are a thing of the past. "Once they're using mobile devices, nurses will be able to move from patient to patient—connecting wirelessly into the network simply by entering each room," he says. "This means they have more time to spend with patients, improving customer service and employee job satisfaction."

For individuals who find going completely paperless more worrisome than comforting, the network is designed with redundancies that guarantee the ability to access data—as long as there's electricity, including a backup system available in the event of power failure.

"Our solutions are deemed to be fault-resilient. We ensure the integrity of the data, and we also ensure that there is always a path to the data," Bontemps explains. "But the facility is responsible for having an uninterruptible power supply to provide power to the servers. We do not control that, but we can help them design the network to become fault tolerant." (For more information on power supplies and issues, don't miss this month's "Absolute Power" article.)

Reforming Telemedicine

RFID makes it possible to closely monitor components of a building, but a system being created at the University of Chicago makes it possible for physicians to interact regardless of how far they are from each other. The Advanced Biomedical Collaboration (ABC) test bed is a technical framework based on the Access Grid, an infrastructure that allows multiple streams of data to travel between multiple locations simultaneously.

"Unlike traditional teleconferencing, it's not point to point; it's very different in that you can have multiple simultaneous streams," explains Jonathan Silverstein, MD, MS, FACS, assistant professor of surgery in the Section of General Surgery at the University of Chicago, director of the University's Center for Clinical Information, and senior fellow of the University's Computation Institute. "[The goal is to] move us beyond telemedicine to telecollaboration, with medical professionals at each of the multiple ends of the system, each giving interpretive information."

The technology holds particular promise for the imaging community, because the data that can be shared—including physiologic information, radiological data, and video—is far more complicated than basic telemetry.

"We've demonstrated that you can use the system to transmit stereo-video signals, meaning the video itself is running in 3-D," Silverstein says, adding that the system is still a prototype. "We will be able to plug directly into surgical devices that send laparoscopic stereo-video signals and transmit over long distances in multiple locations, allowing a group of people to see—in 3-D—the anatomy being operated on."

To help minimize the draw on available bandwidth, the ABC test bed will feature a type of visualization system that allows users to send video streams in pieces rather than as one large file.

"You'll be instantly loading it in one place and opening a channel to somewhere else," Silverstein says. "You don't have to send the entire DICOM data set, just the information you're visualizing."

Though much of the work is still in development, some University of Chicago anatomy students will benefit. As part of a pilot program, students will look inside the human body—without actually seeing one.

Through the "Virtual Anatomy" course offered in the spring semester, University of Chicago students will have a "cadaver" in the form of high-resolution CT scans.

"By changing the dynamic range of the data and using three-dimensional cutting planes, we explore and find the interesting anatomy the way you would with a cadaver," Silverstein says, adding that a color algorithm created by his team automatically applies colors based on tissue type. Because all of the course data is housed on the Access Grid, students can log on to access their "body" from any location, at any time. "Students can use the same tools on their desktop, and it can be three-dimensional," he says. "In a sense, the textbook can really come alive."

Communication Breakdown

There's no denying that automation and technology improvements have brought a host of benefits to radiology, but the transition to a filmless, PACS-powered world has not been flawless.

"We are a completely filmless hospital, which is good, because we don't lose anything anymore, the quality is always uniform and high, and the images are available moments after the study throughout the entire hospital, including private offices and physicians' homes," says Reuben Mezrich, MD, PhD, chairman and professor of diagnostic radiology at the University of Maryland Medical Center (Baltimore). "The bad thing is it all gets in the way of communication between the referring physicians and me."

Gone are the days when the radiology department controlled the dissemination of study images. Unfortunately, when referring physicians are able to access images without visiting the radiology department, they will do just that—altogether eliminating the discussions that often took place as the film was reviewed.

"We've lost that dialogue, and sometimes, a conversation about why a physician ordered a particular study is a good conversation," Mezrich says. "The field is changing so fast, it's important to know what information he's hoping to obtain to find out what study is the best to order—is it a plain film, an MR, a CT, or a PET? This is where there should be communication, and we've lost it."

But Mezrich is confident that technology can help remedy some of the ailments that it has created. Early this year, his radiology department will start a pilot program with a simple goal: to increase the flow of information throughout the facility.

The team will experiment with a variety of options to determine the best possible solution—or combination of solutions—focusing on wireless tools, including mobile phones, PDAs, laptops, and tablet PCs. Mezrich even brought in a few iPods. The plan is to use them to distribute informational videos—akin to Podcasts—relating to either specific patients or providing general educational information.

"We're exploring and studying the best way to communicate," he says. "After the trial in the department, hopefully sometime this summer or this fall, we'll spread it around to the rest of the hospital." In a culture where no one "owns" film—when, in fact, film is fading fast—Mezrich wants to make sure the radiologist's role evolves and thrives.

"What is the value added from a radiologist now that images are sent around the hospital instantly?" Mezrich asks. "It is the intelligence we add to the image. If that isn't there when the referring physician is providing care, then we're not providing care; we're doing quality control. We want to provide care, so we must have the best communication tools available."

Mezrich and his team are making use of a myriad of options with technology from MobileAccess Networks Inc (Vienna, Va), which delivers in-building solutions for cellular coverage regardless of the wireless service providers.

Direct to the Patient

Clinicians are not the only ones who are benefiting from the technology boom. In the near future, mammography patients from the Westchester Medical Group (White Plains, NY) will have the option of completing their prescreening survey on a freestanding kiosk.

Using a touch screen, patients can complete a mammography questionnaire, which is reviewed by an assistant and then goes directly into the facility's EMR system. After the exam is complete, images are attached to the report and are only a click away any time the patient's record is accessed.

By automating this step of the process, it provides the opportunity for radiologists to interact with patient information in a completely new way.

"When a physician brings up the images to read a mammogram, he or she also launches the electronic medical note," explains Simeon A. Schwartz, MD, president of The Westchester Medical Group, and clinical associate professor of medicine at Cornell University School of Medicine (Ithaca, NY). "In our PACS, when the report is sent to the EMR system, the image is included as an attachment, allowing any physician reviewing the X-ray reports to see the X-ray with a click of the mouse.

"Here's what a radiologist is going to look like in the new world," Schwartz continues. "On the left-hand side of the monitors, he or she will have the EMR and, in the case of mammography, the completed questionnaire. The report of the mammogram will go into the EMR when he or she signs it, and he or she will click the tracking system at the same time, which is in the note of the EMR. This process requires the physician to provide some information, such as the 'next anticipated date' and whether the findings were 'normal/abnormal,' among other details. This way, we have three things in one file: the report, the image, and proof that the radiologist reviewed the mammography form that was completed by the patient."

A Rapidly Approaching Future

Andy Warhol once said, "They say that time changes things, but you actually have to change them yourself." This statement is appropriate especially, it seems, for those on the forefront of imaging technology. Technology alone would not have the impact that proactive physicians and researchers are able to make, simultaneously increasing physician convenience and accessibility and, ultimately, improving patient care.

Dana Hinesly is a contributing writer for Medical Imaging.