In this thesis the impact of digitisation on radiology is analysed based upon diverse initiatives and research projects that were conducted in the period between the early days and now. Various topics such as web-based sharing of radiological images, teleradiology, digital communication and advanced processing of medical data, are discussed. Based on these findings the author formulates his vision and advises about the future role of the radiologist. In the dissertation The impact of information technology on radiology services the author describes the most important changes that took place in the field of information technology since the end of past century, and their impact on radiology. A real revolution has been provoked in radiology by the complete digitisation of medical imaging and the deep integration of Internet in both society and healthcare. Digital archiving, processing and distribution of radiological images, as well as the development of various types of teleradiology, are an important part of this change. Radiology is facing many new challenges and opportunities due to the on-going exchangeability, integration and automated analysis of medical data and images. Other major trends such as the increasing personalisation of medicine and growing engagement of patients in their healthcare process are also significantly influencing this turnaround in radiology.

2. Introduction
Chapter 1

3. Major trends
• Growing digitisation of society & medicine.
• Mobile communication.
• Growing costs in HC.
• Great faith in telemedicine.
• Patient empowerment.
• Holistic view in medicine and radiology.

4. Internet
Mobile
devices
Health
Care

5. WHEN WIRELESS IS PERFECTLY APPLIED
THE WHOLE EARTH WILL BE CONVERTED INTO A HUGE BRAIN
(Nikola Tesla, 1926)

6. Aims and OBJECTIVES
Chapter 2

7. Questions

8. Methodology
Q1: What is the impact of digitisation and Internet on radiology services?
Q2: Did Internet allow the creation of useful tools for radiologists and patients?
Q1: What is the impact of digitisation and Internet on radiology services?
Q2: Did Internet allow the creation of useful tools for radiologists and patients?
Q3: What were the key factors for the development of teleradiology?
Q4: What services are included in teleradiology?
Q5: How did teleradiology develop in the EU vs. the US?
Q6: What is the future of teleradiology?
Q3: What were the key factors for the development of teleradiology?
Q4: What services are included in teleradiology?
Q5: How did teleradiology develop in the EU vs. the US?
Q6: What is the future of teleradiology?
Q7: How will the major trends influence radiology?Q7: How will the major trends influence radiology?

9. Radiology and internet:
from the first steps to the revolution
Chapter 3 and 4

10. Propositions
1. The widespread adoption of the Internet has
resulted in the availability of new tools and
services for both radiologists and patients.
2. The digitisation in medical imaging and
availability of high-bandwidth Internet have a
significant impact on the way radiology
services can be delivered.

11. Radiology and Internet: first steps
• Early days - Web 1.0
– “Static” web pages
– Users are “consumers of content”
– Social interaction only via e-mail,
discussion groups, newsgroups
• Web 2.0
– “Architecture of participation”
– Users provide data & generate
content
– Development of social media, more
social interaction between users
– “Collective intelligence”

12. Web 1.0 example
• EUFORA mailing list, 1998 – 2001
• Discussion group for radiologists
• Linked to image database CONRAD (jpg)
• Users:
• 460 members
• > 48 countries
• 2-3 messages/day
• “Collaborative” medium:
• Exchange of information
• Requests for second opinion
• Group-wise presentation of cases
• Objective :
• Stimulate radiologists in using e-communication
• Support them in their continuum of learning

13. Join the discussion!
Create discussion

14. Web-based
image sharing and distribution
• Thanks to the WWW images and
patient data can be shared more
easily.
• Web-based tools were created for
displaying and manipulating medical
images.
• Images could be viewed on any PC or
other (mobile) device.
• It became possible to communicate
and discuss images online.

15. Web-based image distribution
PACS
Viewing
station
Viewing
station
Web Server
CR CT MRI US
Viewing devicesRadiologists
Modalities

16. Revolution in radiology
• Information technology (IT) has led to the
digitisation of radiology.
• Images are created, stored, transmitted and
analysed digitally.
• The digitisation is associated with other
technological developments, such as PACS, RIS
and HIS.

17. Digitisation of radiology

18. Radiology workstation

19. The digital radiology department
Billing
HIS RIS Speech
Bridge
PACS
Viewing
station
Modality
DICOM
HL-7
Patient Radiologist
HIS = Hospital Information System
RIS = Radiology Information System
PACS = Picture Archiving and Communication System

20. New development: the Cloud
Traditional image storage
• “Siloed” architecture
– Intensive & expensive to manage
– Insufficient bandwidth
– Vulnerable to failure & downtime
– Different for each site
Cloud-based image storage
• “Virtualized” architecture
– Shared & cost-effective storage capacity
– High speed accessibility
– Single point of access: EPR, Portals
– Elimination of redundancy
Site 1 Site 2 Site 3
…
Site 1 Site 2 Site 3
…App 1App 1 App 2App 2 App 1App 1 App 1App 1 App 10App 10 App 1App 1 App 2App 2 App 1App 1 App 1App 1 App 10App 10
Cloud based storage platformCloud based storage platform
Source: SIIM Webinar Jan 28, 2016: “Real world challenges and benefits of cloud technologies”

21. teleradiology
Chapter 5

22. Propositions
1. The ability to electronically share patient-related
information and radiological images has been key to the
development of teleradiology
2. Teleradiology is a broad term for a variety of applications
in which radiological images are shared electronically
3. Teleradiology has developed in a different way in the EU
and the US
4. Teleradiology is here to stay, although the format by
which teleradiology services are delivered is likely to
change

23. Chapter 5
1. Teleradiology: evolution and concepts.
2. European teleradiology now and in the
future: results of an online survey.
3. ESR White Paper on teleradiology: an update
from the Teleradiology subgroup.
4. Comparison of European (ESR) and American
(ACR) White Papers on teleradiology: patient
primacy is paramount.

24. The doctor of the future
“The doctor of the future” using radio and television to give a
consultation to his patient aboard the ship ‘India’ in the South Seas.
1939, © Fritz Kahn - www.fritz-kahn.com
“The doctor of the future” using radio and television to give a
consultation to his patient aboard the ship ‘India’ in the South Seas.
1939, © Fritz Kahn - www.fritz-kahn.com
TeleradiologyTeleradiology

25. Development of teleradiology
• Key-factors:
– Shift from analogue to digital imaging
– PACS (Picture Archiving and Communication Systems)
– High Bandwidth
• Possible through availability of mechanisms to
quickly and affordably transmit digital data
over large distances

26. What is teleradiology?
• Teleradiology is part of telemedicine.
• Variant of radiology, existing medical practice.
• Remote activity by radiologist.
• Electronic transmission of patient data.
– Examination request + relevant clinical information
– Radiological images + priors
– Patient-identifiable health-related information
• Crossing boundaries of hospital/organisation.
– Sometimes across national boundaries

27. Teleradiology applications
15. Social Media15. Social Media
13. Case presentations

28. Teleradiology models
Peripheral Hospital
Private Diagnostic Centre
Peripheral Hospital
Private Diagnostic Centre
Hospital group
Regional network of hospitals
Hospital group
Regional network of hospitals
Teleradiology companyTeleradiology company
• On-call radiologist’s home • Insourcing, distribution of workload
• Intra- and inter-institutional
• Emergency readings, expert
opinions (trauma, stroke…)
TR
OutsourcingOutsourcing
TR
Commercial
TR services
OutsourcingOutsourcing
LocalLocal Regional
National
Regional
National
National
International
National
International
Insourcing
OutsourcingOutsourcing

29. Progressive shift of discussion
10 yrs

30. Chapter 5
1. Teleradiology: evolution and concepts.
2. European teleradiology now and in the
future: results of an online survey.
3. ESR White Paper on teleradiology: an update
from the Teleradiology subgroup.
4. Comparison of European (ESR) and American
(ACR) White Papers on teleradiology: patient
primacy is paramount.

31. Survey background
• Overview of teleradiology
usage in Europe
• Evaluation of opinion about
teleradiology
• Evaluation of future role of
teleradiology
• Online survey
• European radiologists
• Sept. – Nov. 2011
• 32 multiple-choice
+ 3 open questions
• 368 participants from 35
European countries
Objectives Materials and Methods

32. Results
• Majority uses teleradiology (TR) 65%*
• Insourcing 71%
• Outsourcing 35%
• Most of TR is used for on-callpurposes 44%
• Commercial TR services used by only 52% of those
who do outsource
• In 15% of outsourcing images are sent cross-border
• Cross-border teleradiology needs better legislation,
price regulation and QA framework
* % of total number of participants

33. General advantages of teleradiology
Agree % Disagree %
Possibility to collaborate 74 11
Improves efficiency 70 13
Ability to sub-specialise 65 13
Better distribution of workload 65 10

34. Outsourcing
Advantages
• Greater capacity
• Faster TAT, 24/7 service
• Availability of subspecialty
knowledge
• Workload reduction,
lifestyle improvement
Disadvantages
• Less communication with
teleradiologist
• Limited access to clinical
data and priors
• Less contact with
radiographers
• Legal issues to be solved
e.g. cross-border in EU
• Price competition

35. Ideas about future
• 80% positive
• 46% thinks its importance will grow
• Most important reasons for growth:
– Shortage in radiologists
– Need for sub-speciality expertise
– Growing need for emergency readings
– Greater flexibility for smaller practices

36. Chapter 5
1. Teleradiology: evolution and concepts.
2. European teleradiology now and in the
future: results of an online survey.
3. ESR White Paper on teleradiology: an update
from the Teleradiology subgroup.
4. Comparison of European (ESR) and American
(ACR) White Papers on teleradiology: patient
primacy is paramount.

37. European agenda: e-Health
• The 'Europe 2020 vision' is opening the way for e-Health.
• e-Health is believed to have the potential to reduce public
expenditure on healthcare.
• Coordinated effort to overcome the current barriers.
• Support of standards for seamless sharing of medical
information (e.g. IHE-XDS).
• Teleradiology is therefore very likely to become an
integral part of healthcare delivery across Europe.

38. ESR position on teleradiology
• 2004 EAR-UEMS Position Paper
• 2006 ESR-UEMS White Paper
• 2009 ESR response to EC communication on telemedicine COM(2008)689
• 2011 ESR response to public consultation on eHAP 2012-2020
• ESR position:
– Medical act
– Need for European accreditation criteria
– Need for international quality standards
– Responsibility of country where patient undergoes exam
– Informed consent

39. ESR White Paper
• e-Health and Informatics
subcommittee
• Teleradiology subgroup
• Collective online discussion of
topics, sharing of information
and writing of paper
• Approval from ESR executive
council before publication
• Update 2006 White Paper:
– On-going digitisation
– EU-promotion of
telemedicine and e-Health
• Comprehensive best-
practice guideline for
teleradiology usage in EU
Objectives Materials & Methods

40. Topics white paper
1 Teleradiology usage in Europe
2 EU Legal framework
3 Licensing and registration
4 Teleradiology as a medical act
5 Patients’ rights and informed consent
6 Liability issues
7 Technology- and security-related issues
8 Work environment and ergonomics
9 Communication principles (incl. language, structured report)
10 Contracting and financing
11 European diploma (EDiR)
12 Teleradiology training

41. Key issues
QA framework:
Q standards and
Q regulations
International
harmonisation of
patient privacy
regulations
GDPR April ‘16
Seamless integration of PACS, RIS, EPR
IHE-compliant IT-systems
More uniform legislation:
protection of patient’s rights,
licensing and liability
National financing
and reimbursement
systems need to be
harmonised
Semantic interoperability:
international lexicon,
standardised terminology,
translation software

42. Chapter 5
1. Teleradiology: evolution and concepts.
2. European teleradiology now and in the
future: results of an online survey.
3. ESR White Paper on teleradiology: an update
from the Teleradiology subgroup.
4. Comparison of European (ESR) and American
(ACR) White Papers on teleradiology: patient
primacy is paramount.

43. Different teleradiology markets
EU US
Type of readings Final Preliminary
Off-hour 44% 44%
Outsourcing 35% 70%
Insourcing 71% -
Competitive pricing Moderate High
Growth >15% Shrinking

44. Common viewpoints
• Patient primacy: patients should come first.
• Quality and safety are essential and have to be maintained.
• TR services need to be fully compliant with local policies and procedures.
• Access to prior imaging studies and patient information is important.
• On-site radiology services are preferable to outsourced radiology services
• Both have fear for further commoditization by outsourcing.

45. Different viewpoints
• Teleradiology concept: outsourcing in US, outsourcing + insourcing in EU.
• Different market situation and politics.
• Cross-border / international vs. domestic teleradiology.
• Informed consent: only in Europe.
• Strengthening position of local radiologists in US vs. uniform European
quality training (EDiR).
• Local language requirements in EU, no language issues in US.
• Communication of critical findings: highly regulated in the US,
in EU recommendation for protocols.

46. Social media in radiology
Chapter 6

47. Proposition
• Major trends, such as the growing usage of
mobile devices, the popularity of social media,
the on-going implementation of telemedicine
and increasing patient empowerment, will
have a significant impact on the way
radiological services are provided.

48. Chapter 6
1. Social media for radiologists, an introduction
2. Radiologists’ usage of social media: results of
the RANSOM survey

49. Web 2.0
• Social media and networks
are a typical Web 2.0
product
• They replace traditional
communication methods
• Mobile devices have
contributed to their success
• They make use of
public cloud services
• On-going shift from Web 2.0
to Web 3.0
Web 2.0 Web 3.0
Real-time data “Think apps”, non-
browser
User-generated
content
Semantic and
meaningful data
Go social! Emphasis on
personal data
Content gathering Portability, clouding
Mobile, WiFi Digital wearables,
Internet of Things
(IoT)

50. Major impact on healthcare
• Radiological images are going
mobile too
• Interesting in emergency setting:
– e.g. Telestroke network
– CT images are sent to doctor on
distance
– Decisions for treatment are made
based upon these images
• Supported by Cloud-based
technology
• Patient safety and security needs
to be protected
Source: http://www.imedicalapps.com, Jul. 10, 2010
ER Ranschaert, Teleradiology

51. Secured cloud-based exchange
Private Cloud
MRI scanner
Radiologist
PACS
server
Institution A
Community Hospital
Physician office
Institution B
Specialty Hospital
Radiologist
Institution C
Community Hospital
Radiologist
51
Mobile device
physician/radiologist/patient

52. Radiologists using WhatsApp
• “At 11 PM I got this picture of an
angiogram from another radiologist
via WhatsApp. The patient was in
coma, almost dead.”
• “He wanted to know more about
what he was seeing on the
angiogram is, and he made a picture
of the angiogram on the screen of the
workstation. I’m specialised in
cerebral stroke and saw that it was a
thrombosis of the basilar artery with
a rare anatomic variant of the
vessel.”
• “I could explain him how to deal with
this abnormality. The patient could be
treated quickly. After the treatment
he woke up and could go home.”
52
Croonen H. Veilig whatsappen een must voor dokters.
Med Contact 2015(48):2312-5.
Geert Lycklama à Nijeholt, Bronovo ZH, Den Haag

53. Social media for radiologists
Benefitsand opportunities
• Improvement of radiologists’ visibility among clinicians and patients.
• Increased interaction with clinicians.
• Exchange of information and knowledge.
• Distribution and discussion cases for education and research.
• Sharing of radiological images with peers and clinicians.
• Increased impact and influence in the medical community.
• Active engagement during scientific meetings.
• Augmenting the visibility of scientific publications .

54. Pitfallsanddangers
• Insufficient or inappropriate legislation and policies in hospitals/practices
• Insufficient separation of personal and professional data
• Insufficient privacy settings (who can see/read what I post)?
• Insufficient protection of patient privacy (informed consent?)
• Lack of obvious guidelines
• Lack of review of published material
Social media for radiologists

55. RANSOM Survey
• Objectives:
– How many, how and
why do radiologists use
social media?
– What are the differences
between EU and US ?
• Online March – May ’15
• 516 radiologists
J Digit Imaging. 2016 Feb 3. [Epub ahead of print]
Radiologists' Usage of Social Media: Results of the RANSOM Survey.

56. Radiologists and SoMe
56
J Digit Imaging. 2016 Feb 3. [Epub ahead of print]
Radiologists' Usage of Social Media: Results of the RANSOM Survey.

57. Major concerns
Insufficient legislation, guidelines and policies for SoMe in healthcare 75%
Risk for privacy of the patients 39%
Risk for privacy of radiologists 39%
Insufficient knowledge about social media among radiologists 37%
Distraction from clinical activities 28%
Deprivation from real social contact with others 18%
Danger of negative comments on our practice 13%

58. What did we learn?
• Most radiologists use social media, private >> professional.
• Most popular professional platforms:
– in Europe -> LinkedIn
– in the US -> Twitter
• European radiologists
– To keep up with the news
– To discuss interesting cases
• American radiologists
– To make radiologists more visible
– To market radiology services
• Radiologists need guidelines and policies to use social media
US EU

59. conclusionS and FUTURE PERSPECTIVES
Chapter 7

60. Overall summary
• 3 major innovations in IT
1. Internet
2. Broadband connections
3. Rise of mobile networking and data exchange
• Impact on radiology
– The filmless, full digital department is now reality
– Teleradiology has many applications and is still evolving
– Standards & guidelines are essential to share images and patient data
efficiently, safely and securely
– A digital & mobile society is developing in which health-related information
can be shared more easily

61. Where are we going?
• Availability of patient’s
health-related data,
independent of time and
location
• Shift from
hospital-centric to
patient-centric hospital
The liquid hospital

62. The liquid hospital
The journey of the autumn leaves, by Theo Bosboom – www.theobosboom.be

63. Shift of HC model
Hospital-centric model Patient-centric model
Hospital centric
Episodic
Departments
Proprietary
Data silos
Patients

64. Future developments

65. Redefine radiology
• Easy & fast sharing of data
• Use of mobile devices
• Embracement of Artificial
Intelligence
• Imaging for personalised care
• Image-guided treatments
• Patient communication
– e-Consultation
– Multimedia reports Eliot Siegel, schooling IBM’s Watson at the University of Maryland;
Image courtesy RSNA.org

66. Multimedia reports

68. “Replace ‘I’ with ‘we’
and
illness becomes wellness.”