Presentation given at the European Congress of Radiology, ECR 2015 in Vienna, March 4th. About usage of mobile devices in radiology, current changes in radiology due to increasing use of mobile devices and growing wireless connectivity. About mobile radiology, m-Health & social media in radiology and medicine

1. Mobile (tele)radiology
Erik R. Ranschaert
e.ranschaert@jbz.nl
ECR 2015

2. Introduction
• What is changing?
• What are mobile devices?
• What is mobility?
• What is teleradiology?
• What is the role of social media?
• What is the impact on health care and
radiology?

3. Internet
(Tele)radiology
Mobile
devices
Health
Care
SoMe

4. What is changing?
• Availability & exchangeability of digital
medical data
• Online health-related services
• Patient empowerment
– management of health data
– radiological images & reports
• Personalized medicine
– diagnostic testing…
– …to select most appropriate therapy…
– …based on patient’s genetic content
• Bertalan Meskó, “20 Predictions in Medicine And Healthcare for 2014”- www.scienceroll.com, Jan 3, 2014
• Frost & Sullivan White Paper, Slide presentation HealthStartup Europe (www.slideshare.net)
• J Am Coll Radiology April 2012

5. Almost anything
- including living things -
will be connected to the Internet
regardless of location or other
physical restrictions

6. Health-related searches
5% of all
searches
are Health-
related

7. Mobile devices and mobility
• HC professionals are
globally rapidly adapting to
mobile technology.
• Smartphones and tablets
are regarded as “the most
popular technological
development for providers
since the invention of the
stethoscope”.
Source: “The road to telehealth 2.0 is mobile”, Calgary Scientific, 2015
Boston Consulting Group & Telenor Group (2013). The Socio-Economic Impact of Mobile Health. Page 6.
http://www.telenor.com/media/in-focus/the-socio-economic-impact-of-mhealth

8. What are mobile devices?
• Smartphones are mainly for
phone calls
• Tablets are mainly for all
other applications
• Mini-tablets become smaller,
smartphones become larger
• Phablet combines tablet and
phone features
• Isn’t a laptop a mobile
device?
Smartphones TabletsPhablets

9. Size of mobile devices
- Large phones (“phablet”) will grab 50% of the market in 2015
- Laptops are not threatened by tablets
- Larger smartphones are “pushing out” tablets
- Tablets need to evolve direction laptops: larger screen, multitasking
60%
small
55%
medium
Pcworld.com, 10 Oct. 2014, Phablet vs. mini-tablet: the big choice between two smallish devices
Tablets aren’t killing laptops, but smartphones are killing tablets, Chris HoffmanHowtogeek.com, 25 Oct. 2014

10. In 2015 iPad Air Pro with 12.2 inches?
2732 x 2048 and 265 pixels-per-inch (ppi)

11. Internet
HealthRadiology
Mobile
devices
Smartphones
Phablets
Tablets
Laptops
Mobile devices

12. What should radiologists use?
• “Careful product selection
and judicious use are
necessary ...”
• “It is the responsibility of
the radiologist to securely
and effectively utilize
mobile technology in the
best interests of patient
care.”
http://www.acr.org/Advocacy/Informatics/IT-Reference-Guide

13. 1
4
3
2 5

14. Display Size of mobile devices
http://www.acr.org/Advocacy/Informatics/IT-Reference-Guide

15. Mobile viewing apps
• USA: FDA approval
• Europe (EU): CE mark
– Apps for medical purposes need to be
registered as medical device,
following the Medical Device
Directive (MDD)
– Ensures safety and performance
– DICOM viewing apps are in lowest
MDD risk category (Class I of III)
– Developers can self-declare
conformity
– Unfortunately very limited use of CE
mark
Rodrigues et al., Radiology smartphone applications; current provision and cautions, Insights Imaging. 2013 October; 4(5): 555–562.

16. Web-based DICOM viewers
• “Zero-footprint”
• No downloading of
patient info necessary
• Independent of
– device type
– PACS-type
• Safe for confidential data

17. Mobility
• Radiologists are discovering new ways to create
additional efficiencies with mobile tools
• Key is to leverage mobility so that you’re able to
benefit from it
• Radiologists must embrace a purpose driven approach
• “Look for the right devices for the right scenarios at
the right places”

18. Example: Telestroke
• 2012 study Mayo Clinic study
• Smartphones connected to
telestroke network in Utah and
Arizona
• “Hubs” of experts connected to
“spoke clinics/hospitals”
• Non-contrast CT identification of
contra-indications for
thrombolysis
• Excellent correlation of CT
findings by neurologists and
radiologists
• Accessing patient images on iPads
is 6 x faster than using a high-
resolution PACS viewer.
• The iPad viewer provided
comparable diagnostic
confidence and ease of use.
Bart M. Demaerschalk et al., Stroke 2012;43:3098-3101
Bart M. Demaerschalk et al., Stroke 2012;43:3095-3097

19. Bart M. Demaerschalk et al. Stroke. 2012;43:3098-3101
Copyright © American Heart Association, Inc. All rights reserved.
Mobile infrastructure and algorithm

20. Terminology
• Currently a wide range of terms is being used:
– eHealth, mHealth
– Telemedicine, telehealth
– Teleradiology
– Virtual imaging
– Digital health
– Wireless health
– Connected health

21. Telemedicine and Teleradiology
Keith J. Dreyer, Amit Mehta, James H. Thrall, Springer Science & Business Media, 2002

22. Applications of Teleradiology
Keith J. Dreyer, David S. Hirschorn, James H.
Thrall, Amit Mehta, Springer Science & Business
Media, 2006
15. Social Media

23. Obsolete term?
PACS, Keith J. Dreyer, David S. Hirschorn, James H. Thrall, Amit Mehta, Springer Science & Business Media, 2006

24. Current usage of teleradiology
• Thousands of systems have been deployed in the US
and Europe
• Many (most?) are “lower end” systems, to provide
emergency (on-call) coverage in radiology practices
• Home workstation is usually a PC, laptop or tablet…
• …for interpreting 512x512 images (CT, MRI, US)
• Expectations are rising concerning the interpretation
of medical images on mobile devices
• Mobile devices used for radiology = mobile radiology
Keith J. Dreyer, David S. Hirschorn, James H. Thrall, Amit Mehta, Springer Science & Business Media, 2006
IT Reference Guide for the Practicing Radiologist (ACR), 2013: Displays

25. Mobile (tele)radiology
PC screen workstation is accessible on tablet after logging in with Citrix platform, (“receiver”)
=> virtual workstation is created, accessible on all kinds of mobile devices

26. Internet
Health
CareRadiology
Mobile
Telemedicine
mHealth
Teleradiology
Mobile
Radiology
Terminology

27. Impact of mobility on radiology
Academic Radiology, 20 (2013) 1495-1505. doi:10.1016/j.acra.2013.09.009

28. Changes for patients
• Clinical logistics:
– Online patient scheduling and check-in
– Information on procedures
– Satisfaction surveys
• Communication of results
– Patient portals: images and radiology reports
– Images can be shared by patients with
others
Academic Radiology, 20 (2013) 1495-1505. doi:10.1016/j.acra.2013.09.009

29. Changes for radiologists
• Improved radiology consultation
– Radiologists-to-radiologist consult (on-call)
– Greater social availability to clinicians
– Bed-side rounding with clinical teams
– Intra-operative guiding of operations (discussion of images)
• Critical or urgent notifications
– Providing timely, critical information complemented by a
brief message, discussion, or video chat on a mobile device
• Usage for management
– Radiation measurement (linked to sensors/devices)
Academic Radiology, 20 (2013) 1495-1505. doi:10.1016/j.acra.2013.09.009

30. Changes for clinicians
• Computer-aided surgery: intra-operative
usage of tablet computers
– e.g. Augmented Reality applications by using 3D
anatomical images based upon CT/MRI
• Computerized Physician Order Entry…
• …integrated with Clinical Decision Support
• Personal Assistance Application (≈ Siri)
Journal MTM 2:2:15􏰀19, 2013 doi:10.7309/jmtm.2.2.4

31. Future applications
• Biotech entrepreneur Jonathan Rothberg with MIT
physicists / engineers
• “Capacitive Micro-machined Ultrasound Transducer”
• Real-time 3D images
• As cheap as stethoscope
• AI integration for automating diagnosis
Source: MIT Technology Review, Nov 2014

33. Artificial Intelligence

34. Scanner at home…?

35. Internet
HealthRadiology
Mobile
Telemedicine
mHealth
Teleradiology
Mobile
radiology
Smartphones
Phablets
Tablets
Laptops
Social media

36. What’s the role of social media?
http://www.radiologybusiness.com/topics/technology-management/googlification-radiology

37. Social media and medical image
• Young physicians are
embracing the digital
revolution
• They want to share
complex or interesting
cases with other HC
professionals
• They use mobile devices
and social media to
transmit medical
images to other doctors
• Patients’ privacy is not
protected on most
SoMe, no secure
platforms
• Personal data cannot be
removed (patient’s face,
tattoo, name)
• No archiving of
interesting teaching
cases possible

38. Instagram for Doctors
• Founded by Joshua
Landy, Canadian IC
doctor
• iOS and Android
• For sharing images of
tough medical cases

39. Officially approved
• Free App
• Started in UK, Ireland,
US, Canada, Australia,
New Zealand
• Growing European
presence, recently the
Netherlands
• Approved by health
authorities in each
country
• HC professionals sign up
and need to go through
process to validate their
medical license
• Automated protection
tools removing sensitive
patient details
• Human privacy
moderation team

40. Figure 1 patient privacy
• Patients' faces are
automatically obscured
by the app
• Users must manually
block identifying marks
like tattoos.
• Each photo is reviewed
by moderators before it
is added to the
database

41. Video chat example

42. Should radiologists engage?
• Are we easy to reach? Always nearby? Never
too busy? Always easy to communicate with?
• Should we engage in SoMe as radiologists, or
can we stay away from them?
• Should residents/clinicians prefer Figure 1 to
solve cases and ask questions about radiology
among each other …
• …instead of communicating directly with
radiologists?

43. Social networking no longer optional
• We HAVE to engage
– To assist residents &
colleagues with interpreting
difficult cases
– To communicate with
clinicians more often and
more efficiently
– To interact online, even with
patients
– To improve clinical care and
advance scientific research
• “Become more social again”
Source: Erik Ridley, Auntminnie Oct. 8, 2014 - http://www.auntminnie.com/index.aspx?sec=sup&sub=imc&pag=dis&ItemID=108728&wf=1
Academic Radiology, William Auffermann et al. – (Acad Radiol, September 25, 2014)

44. Security risk of mobile devices
• Mobile devices = vulnerable
to loss/theft
• Patient information can be
downloaded without
encryption
• Images can be shared
through public platforms or
cloud technology, not
designed for storing
protected patient
information (PHI)
McEntee et al: 5 April 2012; Proc. of SPIE Vol. 8318 DOI: 10.1117/12.913754

45. Privacy
https://nakedsecurity.sophos.com/2015/02/26/how-nine-out-of-ten-healthcare-pages-leak-private-data/

46. http://www.technologyreview.com/news/533631/2015-could-be-the-year-of-the-hospital-hack/

47. Hospital hacking
• 600% increase in attacks in 2014
• Medical records often contain both identification
information and financial information.
• Connection of smartphones, tablets, and various
medical devices to health-care facility networks
could introduce new vulnerabilities
Source: Mike Orcutt, MIT Technology Review, Dec 23, 2014

48. Protection
• “In the next half of
this decade, as much
attention must be
paid to deep medical
learning to pre-empt
illness as to data
security to protect
the privacy of
individuals.”
Eric J Topol et al., Digital medical tools and sensors, JAMA, 2015 vol. 313 (4) pp. 353-354.

49. Information of patients
• Health Care professionals should
– ensure that their patients understand what the
information that’s being collected is being used
for, how it may be disclosed, and that they agree
to these.
– understand their own
institution’s policies about collecting,
sharing, and storing information on
mobile devices.

50. Summary
• Radiologists need to consider a mobile strategy
– not only to view images for diagnosis on a consultative
basis,
– but also to enrich the referring clinicians’ experience and
– to improves the patient’s health care process
• It’s the responsibility of the radiologist to securely
and effectively utilize mobile technology in the best
interests of patient care.
• Guidelines are needed with the intention to facilitate
this process and to protect the patient’s privacy &
security.

51. Radiology-starship “Enterprise”
The Wall Street Journal, Jan 26, 2015
View from “the bridge”,
controlling all patient
information
Mobile imaging performed by
“soldiers” with the Star Trek-style
Tricorder