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iPad for (tele)radiology, a critical appraisal


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presentation given at ECR 2013 during the session "Tablets in radiology: friend or foe?"

Published in: Health & Medicine

iPad for (tele)radiology, a critical appraisal

  1. 1. Tablets for mobile (Tele- )radiology a critical appraisal Dr. Erik R. Ranschaert Radiologist ECR 2013
  2. 2. Introduction1. Mobile imaging – trends and evolution2. Technical aspects – Display – Bandwidth – Safety & Security3. Clinical use cases – Mobile Radiology – Teleradiology
  3. 3. Popularity of tablets• More than 80% of physicians own and use mobile devices• Medicine is one of most obvious use cases – doctors are mobile – work in spaces covered by Wi-Fi – Have heavy information needs• Approx. 25% of radiologists are using them clinically Source: Diagnostic Imaging website; accessed Nov 25th 2102 “Taking the Pulse U.S. 2012,” Manhattan Research “Mobile computing in radiology: challenges and benefits.” Diagnostic Imaging, Feb. 12, 2013
  4. 4. Why are iPads so popular among radiologists? Convenience High potential• Versatile, portable, high quality • To improve display, touch screen communication, collaboration, co• Low price vs other LCD displays nsultation and teaching• access to data from multiple sites • To “streamline” communication• reading of emergency cases and strengthen relationships with (CT, MRI) comparable to PACS referring physicians workstations* • To improve relationships with patients by displaying images on a more familiar device *John S et al. The iPad tablet computer for mobile on-call radiology diagnosis? J Digit Imaging. 2012 May 5.
  5. 5. Disruptive technology • A disruptive technology = new product that eventually disrupts the business model of the “incumbent” technology • Characteristics: simpler, cheaper, lower-end, more convenient • Not necessarily as good as higher- end equipment, but good enough • Performance/quality progressively improves • Diagnostic-quality mobile readers will soon be commonplaceHow low-end disruption occurs over timeSource: Wikipedia
  6. 6. Caution• despite the appeal of the iPad, using it requires a thoughtful approach• we need to be careful not to implement technology for the sake of technology• If radiologists don’t analyse it and understand it we may not get the full benefit
  7. 7. iPad and teleradiology• Is iPad suited for (tele)radiology purposes? • Technical aspects • Clinical use cases • Experience, testimonies
  8. 8. Technical aspects• Various technical aspects need to be considered: 1. Display 2. Software (viewers) 3. Bandwith 4. Security and Safety
  9. 9. Size 9.7 inch = 25 cm• . – for diagnostic purposes a display needs to be 20-24 inch (51-61 cm) diagonal, unless using a larger panel to serve as pair of monitors 21.3 inch = 54,1 cm – for clinical review: anything goes• iPhone is 3,5 inch (9 cm)• iPad is 9,7 inch (25 cm) Copyright E. R. Ranschaert
  10. 10. Resolution of display• Ideally 2-3 MP for diagnostic purposes• 5 MP is required for mammography
  11. 11. Luminance of display• DIN 6868-157 = German Industry norm• Luminance: Source: Image quality assurance in diagnostic X-ray departments - Part 157: RöV acceptance and constancy test of image display systems in their environment (2012)
  12. 12. Specifications iPad Barco MDCC- iPhone 4 mini iPad3 iPad 2 7.9” 2121 “Retina” “Retina” 1024 x 768 0.8 MPDisplay 163 PPI 21.3” 3.5” 9.7” 9.7”IPS LCD 1600x1200 960x640 1024x768 2048x1536Resolution (2 MP) (0,6 MP) (0,8 MP) (3 MP) 430 cd/m2 370 cd/m2Max luminance 700 cd/m2 480 cd/m2 (ACR advises 171) (decrease vs iPad2)Pixel Pitch 0,270 mm 0,078 mm 0,192 mm 0,096 mmPPI (dots/inch) 120 326 132 264Contrast ratio 1100:1 1242:1 775:1 839:1Color depth 30 bit 24 bit 24 bit 24 bit/pixelPrice 4500 $ 590 $ 399-529 $ 499-699 $ Copyright E. R. Ranschaert
  13. 13. Pixel Pitch • iPad3 has smaller pixel pitch than diagnostic LCD • iPad3 can display smaller iPhone details but overall image is smaller Megapixels Pixel pitch • Smaller PP does notLCD 1-2 MP 0,280 mm necessarily mean betterLCD 3 MP 0,210 mm performance for clinical task:LCD 6 MP 0,200 mmiPhone: 0,6 0,078 mm • Human sight might not beiPad2: 0,8 0,192 mm able to see smaller detailsiPad3: 3 0,096 mm without aid of magnification
  14. 14. Contrast ratio• ability to produce the bright whites and the dark blacks• DIN 6868-157 requires ratio ≥ 100:1 for diagnosis• AAPM requires • 250:1 for diagnosis • 100:1 for clinical review• CR changes rapidly with viewing angles – ± 10:1 for viewing angles of ≥ 85° Sources: Carrein G, Barco White Paper on characteristics of CRT and LCD displays Indrajit et al., Indian J Radiol. Imaging 2009
  15. 15. Contrast ratio• LCD’s range from 450:1 - 600:1• can be as high as 1000:1• ratios > 600:1 provide little improvement• iPad contrast ratio is 839:1 Source: Carrein G, Barco White Paper on characteristics of CRT and LCD displays Indrajit et al., Indian J Radiol. Imaging 2009
  16. 16. Color bit depth • number of bits used to describe the color of aBit depth Color single pixel combinations2 bit 22 2 • knowledge of color bit4 bit 24 16 depth is useful when8 bit 28 256 working with color16 bit 216 65.536 Doppler and CT/MRI24 bit 220 16.777.216 with color-encoded32 bit 24 + 8 bit 16.777.216 functional imaging • ≥ 30 bit = “deep color” Source: Indrajit et al., Indian J Radiol. Imaging 2009
  17. 17. Influence of ambient light • Importance of ambient lighting conditions • Highly reflective touch screen – Influence of sun and lights – “fingerprints” – viewing angle • Calibration tools?Source: Review Apple iPad 3rd Gen. 2012 4G TabletJ. Simon Leitner / Klaus HinumSource: Indrajit et al., Indian J Radiol. Imaging 2009 Copyright E. R. Ranschaert
  18. 18. Calibration issues• High quality display needs reliable calibration to make a confident diagnosis• iPads have high quality displays – luminosity, contrast and pixel density even better than professional LCD• iPad has – No DICOM calibration – No quality assurance during display’s life – No contrast control
  19. 19. Calibration iPad• iPad: – no access to video subsystem for calibration – impossible to use a utility operating separately from viewing application (as in PACS) – no photometer• Solution: – “Tap test” to adjust compliance with DICOM curve Barco QA Web mobile
  20. 20. Display properties tablets• viewing angles, brightness and contrast levels can match up to diagnostic monitors• Mobile displays cannot compete with the screen size and resolution of modern medical displays – they may play an important role in radiology – they cannot replace but they can function as cost-effective extension of workstations Source: Székely et al, EJR 2013 Copyright E. R. Ranschaert
  21. 21. Technical aspects1. Display2. Software (viewers) a. Viewing software b. Volume rendering sw3. Bandwith4. Security and Safety
  22. 22. Viewing software• Mobile MIM viewer – First mobile app for diagnostic radiology to receive FDA clearance – cleared in February 2011, process started in 2008• approved for viewing images and making medical diagnoses in – CT, MRI and nuclear medical technology• mammography is specifically excluded
  23. 23. FDA regulation of mobile viewers• Since the approval of mobile MIM the FDA has put greater focus on medical mobile apps (software)• Although FDA has not yet released its official guidance for mobile medical apps, industry experts anticipate the agency to claim regulatory authority over any app that helps providers make a diagnosis• Currently mobile DICOM viewers can only be used when and where there is no access to a workstation Source: FDA clears first diagnostic radiology application for mobile devices Diagnostic Imaging, Feb 12, 2013
  24. 24. Top Five Apps for Radiology• Mobile MIM*• Resolution MD mobile*• eFilm mobile HD• Osirix HD*• iClarity All these viewers have basic viewing functionality and safe connection protocols Source: RSNA 2012 poster LL-INE2523 R. Delgado et al: Radiologic Images on Your iPad: Top Five Apps* approved by the US FDA for its clinical use when a close by workstation is not available
  25. 25. HTML5 DICOM viewers• DICOM web-viewers can be used without installing additional software• “Zero-footprint” principle: no installation, no data storage at client• Advantage for security reasons• Cross-platform usage• Vendor-neutral: possible to integrate with any PACS
  26. 26. 3D volume rendering apps• Turns the iPad into a mobile workstation• Postprocessing in real- time on mobile device• Resolution MD
  27. 27. Technical aspects1. Display2. Software (viewers)3. Bandwith4. Security and Safety
  28. 28. Wi-Fi for image transmission• For routine reading on large Network type Speed Speed immobile train/car monitors ± 3-5 Mbps is needed• Small screens mean less need Wifi 802.11 b 5,9 Mbps - for speed thus less BW• Wavelet technology needs less Wifi 802.11 g 25 Mbps - speed (“visually lossless” Wifi 802.11 n 100 Mbps - compression technique)• Mobility goes at cost of slower 3G 14 Mbps 144 Kbps (2 Mpbs real) downloading speed – E.g. CT skull with 3G 4G 1000 Mbps 100 Mbps – 10 sec (still) vs. 3 min (mobile) Source: Choudri AF et al, J Digit Imaging 2011 Apr 24(2):184-9 Copyright E. R. Ranschaert
  29. 29. Copyright E. R. Ranschaert Mobile data transmission Est. image size Est. transmission speed Resolution MB 3G 4G 2 sec (S) < 1 sec (S)Chest X-ray 2048 x 2400 x 16 1,6 – 3,2 3 min (M) < 1 min (M) 10 sec – 3 min (S) 1 sec (S)CT 512 x 512 x 16 20 - 200 15 min – 2 h (M) 16 sec (M) 1 – 10 sec (S) < 1 sec (S)MRI 256 x 256 x 8 2 - 20 2 – 15 min (M) 1 sec (M) S = still, M = moving
  30. 30. Technical aspects1. Display2. Software (viewers)3. Bandwith4. Security and Safety Copyright E. R. Ranschaert
  31. 31. BYOD• Bring Your Own Device• Risk: – Lack of essential security controls – Higher risk of malware infection – Potential loss/theft of mobile devices
  32. 32. iPad & Security risks• Consumer device: not designed for protecting sensitive patient data• Risk to the security of patient records if downloaded & stored on tablet• Risk if images are shared using unsecure platforms McEntee et al: 5 April 2012; Proc. of SPIE Vol. 8318 DOI: 10.1117/12.913754
  33. 33. Secure image sharing? • Dropbox? ✗ • Allows to uploading and sharing of images • Dropbox does not have HIPAA certifications for use in health care settings
  34. 34. Copyright E. R. Ranschaert Massive increase in data breaches• 97% of US clinicians access patient data on mobile devices• Only 38% of HC organisations in US have mobile saftety policies• 94% of US hospitals had data breach in past 2 yrs• In 2010 only 30% reported >5 incidents• Most important cause is loss or theft of portable digital equipment (46%) Source: Third Annual Benchmark Study on Patient Privacy & Data Security, Dec 2012 Diagnostic Imaging,Feb. 12, 2013: 2011 HIMSS survey
  35. 35. Copyright E. R. RanschaertTablets are vulnerable to loss/theftSource: Third Annual Benchmark Study on Patient Privacy & Data Security, Dec 2012
  36. 36. Measures to be taken• Adapted IT logistics for wireless network• Mobile Device Management Tools – creation of “safe environment” on BYOD – access after security check – data remain within “safe container” on device – data not accessible for other “private apps” on device – remote “wiping” of container is possible• Increased insurance premiums for hospitals• Image sharing through secured platforms only Copyright E. R. Ranschaert
  37. 37. Image32• Secure accounts• Protected health-information is stripped-out: name, MR number• Only study-identifiers, no patient- identifiers• On-line sharing and simultaneous viewing on any device• Online viewer is class-I device: not for diagnostic use
  38. 38. Clinical use cases• most wanted in emergency setting – CT brain for evaluation of acute stroke – Chest XR detection of pneumothorax – CTA chest for pulmonary embolism• Accurate and fast, similar results to reading workstationSource: kely A, et al. Smartphones, tablets and mobile applications for radiology. Eur J Radiol (2013)
  39. 39. Other clinical use-cases• Chest: – Chest CT for pulmonary nodules (metastases) – Chest XR for tuberculosis• Abdominal: – CT appendicitis – Virtual colonoscopy• MSK – spine MRI (spinal injury) – Knee MRI Image of patient with gout is displayed with syngo.via WebViewer. (Provided by Siemens)
  40. 40. User’s experience Copyright E. R. Ranschaert
  41. 41. User’s experience (1) • Screen OK for CT/MRI • Not for X-ray/mammo • Good for on-call radiologists • Good for giving second opinion to clinician/resident • Bed-side demonstration • Not for routine reporting Copyright E. R. Ranschaert
  42. 42. User’s experience (2)• Main concern is lack of DICOM-calibration• Fine for less demanding modalities or maybe selected radiographs ... Copyright E. R. Ranschaert
  43. 43. Advantages iPad for radiology Hardware Software• Convenience, versatility • Easy-to-use viewer apps• Flexibility: inside and • 3D viewing software outside radiology dpt. • HTML5 viewers for safe access to images and RIS• High res touch screen information• Long lasting battery • Image sharing is facilitated• Low weight • Integrated communication tools• Low price • Multi-tasking Copyright E. R. Ranschaert
  44. 44. Disadvantages iPad for radiology Hardware limitations Software limitations• Screen size, single screen • No DICOM calibration• Touch screen only • No hanging protocols• Processor and memory • No integration of priors limitations • No functional & volumetric• No multi-tasking assessments• Limited security of tablets • No access to RIS worklist* • Scrolling difficult – strain to fingers – difficult to control speed *Exception: HTML5 viewer Copyright E. R. Ranschaert
  45. 45. Emerging teleradiology applications • free mobile application • cloud based • instant consultation • helps – solo-radiologists – practitionars in remote in areas – those who cannot afford PACS
  46. 46. Conclusion• Mobile devices – should not be used for routine primary diagnosis – need adapted safety policies and ICT environment – are causing a shift towards easier image sharing & communication with peers, referring doctors and patients• They are therefore likely to reshape radiology
  47. 47. Thank you!