EDITORIAL 5 ASSOCIATION NEWS 6 EU NEWS 8 INDUSTRYNEWS 13 COVER STORY 16Teleradiology:The Way Forward >> prof. Iain McCall

EDITOR-IN-CHIEF 17New EU Frontiers for Teleradiology >> Prof. Johan G. Blickman P ROF .I AIN M C C ALL (UK)

EDITORIAL BOARD 18 The FutureofTeleradiology >> Prof. Peter M.T. Pattynama P ROF .J.G.B LICKMAN ( THE N ETHERLANDS) P ROF .G EORG B ONGARTZ (S WITZERLAND) 20 Teleradiology in India P ROF .H EINZ C ZEMBIREK (A USTRIA) >> Dr. JR Raja P ROF .N EVRA E LMAS (T URKEY ) >> Kasi Viswanathanama P ROF .G UY F RIJA (F RANCE) 22 ECRTeleradiology Session Preview P ROF .P AOLO I NCHINGOLO (I TALY) P ROF .L ARS L ÖNN (S WEDEN) FEATURES P ROF .H EINZ U.L EMKE (G ERMANY) 24Managing Large-scale ResearchProjects P ROF .J ARL AJAKOBSEN (N ORWAY ) >> Aad van der Lugt P ROF .M IECZYSLAW P ASOWICZ (P OLAND)

G IAN A NDREA R OLLANDI (I TALY) 25Neuroimaging in Geriatrics

P ROF .U DO S ECHTEM (G ERMANY) >> Dr. BobBarber P ROF .R AINER S EIBEL (G ERMANY) 26 DigitalVersus ComputedRadiography D R .N ICOLA H.S TRICKLAND (UK) >> DervlaSains P ROF .H ENRIK S.T HOMSEN (D ENMARK)

P ROF .V LASTIMIL V ALEK (C ZECH R EPUBLIC) 28Cost-effectiveness in RadiopharmaceuticalR&D

P ROF .B ERTHOLD W EIN (G ERMANY) >> Lars Vedin 29Technology Forecast -Imaging Services CORRESPONDENTS >> ECRI Europe P ROF .F RANK B OUDGHENE (F RANCE)

N ICOLA D ENJOY (B ELGIUM) ECRI HEALTHCARE PRODUCT COMPARISON CHART 31 J OHAN D E S UTTER (B ELGIUM)

S ERGEI N AZARENKO (E STONIA) MY OPINION

D R H ANNA P OHJONEN (F INLAND) 36 Interview withJonathanElion COUNTRYFOCUS GUESTAUTHORS 38The DanishHealthcareSystem D R .B OB B ARBER >> Asger Hansen D R .B IRTHE H ØJLUND B ECH P ROF .JGBLICKMAN 39DanishSociety of Radiology J ONATHAN ELION >> Dr. Birthe HøjlundBech P ROF .A LBERT G JEDDE 40Department of DiagnosticRadiology at Copenhagen University A SGER H ANSEN >> Prof. Henrik Thomsen P ROF .P ETER M.T.P ATTYNAMA D R .JR R AJA 42MR Researchat Aarhus University Hospital H ANS S TØDKILDE-J ØRGENSEN >> Hans Stødkilde-Jørgensen H ENRIK T HOMSEN 43Brain Researchat Aarhus PETCentre A AD VANDER L UGT >> Prof. Albert Gjedde L ARS V EDIN K ASI V ISWANATHANAMA CONGRESS PREVIEW 44 AGENDA 48

Editorial

This edition of IMAGINGManagement focuses on a subject, whichis close to the hearts of radiologists all across Europe – teleradiology. Thereareamyriadofchanges and challenges that the introduction of teleradiology has brought,and our cover story addresses this issuefrom anumber of angles.The first,by Prof.JohanBlickman,focuses on how the EU is working toiron out AUTHOR the numerous obstacles that stand in the way of the futureofEuropean teleradiology.This is followed PROF.I AIN M C C ALL by acogent argument by Prof.Peter Pattynamaon why radiologists must adapt to the changes that E DITOR- IN-C HIEF teleradiology is already bringing, withissues suchas data security,quality control and the multi-disci- E I C@IMAGINGMANAGEMENT. ORG plinary approach wemust take as imaging professionals in order to re-define our value.

Therearemany leading medicalinstitutions within Europe who arealready providing anot in- considerable level of teleradiology services toless well-equipped facilities.Having seen how our US counterparts have taken advantage of the growing telemedicine industry in India, experts Dr JR Raja and KasiViswanathan,provide anoverview of the technicaland management issues that come into play.This edition’s features areled by anarticle from Dutch radiologist AadVanDer Lugt, working as Project Leader for Europe’s largest population-based study,examining the role imaging plays in preventativecarefor at-riskgroups suchas the elderly.This is followed by alook at the growing contrast media segment,and how costs canbe saved in radiopharmaceuticalR&D.Thereis no doubt that large pharmacompanies canlearnfrom the examples provided by small- tomid-sized companies engaged in the same activities,in terms of cost-efficiency and staff management.

Denmarkis the subject of our country focus section,a timely one now that its government have decided to reduce the number of counties,and enact amajor revision of whereand how services will beprovided. The DanishSociety of Radiology play akey role in advising the NationalHealthBoardin Denmark,on whereimaging services need tobehoused,and how improvements canbemade that will increaseefficiency.Wehavealsofocused on imaging researchactivities in Denmark, to show what significant projects are underway and how they aremanaged.

As usual, we welcome your thoughts and feedback. Please send your comments to [email protected]

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 5 AAssssociaotioncNieawstion News

Programme TopicsMIR 2006

A NTONIO S ANTORO WWW. EWGMR. ORG MIR @ EWGMR. ORG NewsUpdatefor IHE Europe

The 9thAnnualMIR (Management InRadiology) ' Emergency Radiology; N ICOLE D ENJOY meeting will beheld this yearinBudapest, ' Standards; DENJOY COCIR ORG Hungary from October 5- 7, 2006.The scientific ' Medico-LegalIssues; @ . programme, whichincludes refresher courses and ' Quality Issues; WWW. IHE - EUROPE. ORG symposia withCME accreditation are continuous- ' Change Management; ly updated.The main topicsare asfollows: ' GeneralManagement:Teaching andReflections. More than 70 companies responded to the call for participation in the next IHE Europeanconnec- ' Radiology Department Organisation; The deadline for submission of abstracts will be tathon tobeheldin Barcelonanext April. During ' Teleradiology; August 20, 2006.Electronicsubmission is required. this connectathon IHE Europe will test the inter- ' RIS-PACS Interaction; operability of the more than100 systems regis- ' ElectronicManagement of RadiologicalData; teredandrehearse the IHE demonstrations ' AcademicRadiology:Teaching andResearch; plannedfor the six following Europeanevents: ' Leadership; Turf Battles andPartnership Strategies; ' ' HopitalExpo,Paris,France,May,16 -19 2006, www.hopitalexpo-intermedica.com; ' SIRM42 Convegno Nazionale SIRM, Milano, Italy 23 - 27 June 2006, www.sirm.org;

The EuroPACS conference,one of the world's aninsidelook at their PACS system. largest gatherings of PACS specialists,hasalso They are inviting submissions of abstracts within announced their call for papers for 2006.This different aspectsofmedicalimaging andPACS: year’sannualedition will take placeJune 15 -17, Integration Strategies,HealthNetwork,Image 2006 in Trondheim,Norway,including between 400 Distributions, the ElectronicPatient Recordand 24thAnnualEuroPACS to 600 delegates from different countries. The con- PACS, Workflow,Cost Benefit andPACS, Security, Conference ferenceprogramme will offer information on the Standardsandmore. Alocalandaninternational latest andmost significant developmentsinclini- programme committee will review the abstracts.

D R .J ARMO R EPONEN calpractice,researchandeducation within digital radiology.Norway hasalong tradition in telemed- Relevant dates JARMO. REPONEN@ OULU. FI icine,pioneering the fieldof teleradiology services January 10, 2006:Workshop andSpecial WWW EUROPACS ORG . . since18 years ago.Today,nearly 100%of the hos- ArrangementsProposalDeadline pitals in Norway haveRIS andPACS.During the March15, 2006:Abstract Submission Deadline EuroPACS haveannounced the 24thedition of conferencedelegates will have the chance to visit April 5, 2006:Notification of Acceptance their AnnualInternationalConference. the new University HospitalinTrondheim andhave May 2, 2006:CameraReady Paper

6 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES updateof the newest developmentsinbiomedical MR by plenary lectures,categoricalcourses,scien- tificandclinicalfocussessions as well asan ConferenceDateAnnounced intense teaching programme. One of the highlights of the conference takes placeonWednesday after- P ETRA J ÄCHE noon when there will beascientificmeeting of the Polish MedicalSociety for MagneticResonance ' Medmatic@, Vicenza, Italy,September 29- 30 OFFICE@ ESMRMB . ORG whererecent achievementsinbiomedicalMR will 2006, www.medmatica.it; WWW. ESMRMB . ORG bepresented. ' WCCWorldCongress of Cardiology 2006, September 2 - 6 in Barcelona, Spain The EuropeanSociety for MagneticResonance The sessions will take placein the Gromada www.escardio.org/congresses/World_Congress_ in Medicine andBiology (ESMRMB) 23rdAnnual ConferenceCentre, whichissituatedclose to Cardiology_2006; Meeting will take place this yearinWarsaw, Warsaw Airport,connectedby bus with the city ' Worldof HealthIT 2006 Conferenceand Poland, September 21– 23, 2006. centre.Warsaw Airport hasdirect connections all Exhibition,October 10 -13, 2006 in Geneva, over Europe,Canada and the U.S.Hotels are Switzerland, www.worldofhealthit.org; The aim of the ESMRMB AnnualMeeting is to available at the conferencecentre andin the city ' Journées Françaises deRadiologie,Paris, exchange scientificinformation andprovidean centre. France,October 21- 25 2006.

Meanwhile IHE Europe continues itscontribution to the development of new Integration Profiles withacontribution on aprofile for medicaldoc- yearcelebrated their 20thanniversary, will cater for ument exchange viaemail or portable media young andoldinterventionalists,and withapprox- (CDROM, DVD, USB stick,etc.) imately 38specialsessions and45 workshops. Similar to the past two years, the emphasis of the Finally,sinceJanuary 1st,Nicole Denjoy, the new programme planning committee was toprovidea COCIR GeneralSecretary,is acting asIHE Europe’s quality programme withquality speakers. For new contact person. novices, thereare many basic workshops to choose from as well as twofoundation courses. The theme of the first foundation course will be Call for Abstractsfor Biliary Intervention and the theme of the second Forthcoming Conference foundation course will beAngioplasty of the SFA. N e ws For the practicing interventionalist,CIRSE 2006 will N INA G REVE cover proceduresincluding VascularImaging, INFO@ CIRSE . ORG Uterine Artery Embolisation,EndovenousAblation, WWW. CIRSE . ORG ClinicalPracticeDevelopment andTumour Ablation. CIRSE (CardiovascularandInterventionalRadiolo- gicalSociety of Europe) hasannouncedacall for N e ws abstract submissions for their forthcoming annual society meeting, which will take placeSeptember 9-13, 2006 in Rome,Italy.CIRSE 2006, who last A ss o c i a t ion A ss o c i a t ion

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 7 EU News

This is the thirdpart in a series that covers the structureand operations of the EU institutions.In the first series (Autumn 2005) weintroduced the EuropeanCommission (EC).

In the second part (Winter 2006) wefocused on the EuropeanParliament –its composition,functioning and main role. In this issue, wecover the role of the Council of the EuropeanUnion. It is the main decision-making body of the EU.

It has the primary role in agreeing legislation –inmost cases together with the EuropeanParliament.SonjaPlanitzer describes the key responsibilities of the Council,its functioning and organisation.

Also,Rory Watson focuses on the current Austrianand coming Finnishpresidency. S ONYA P LANITZER

E DITOR E UROPEAN A FFAIRS The finalpart in this series,for Summer 2005, EUROPE @ EMCEUROPE . COM will cover the Court of Justice.

Council meetsindifferent configurations, THE COUNCIL OF THE within whicheachcountry is represented by the minister responsible for that subject. EUROPEAN UNION If the Council,for example,is todiscuss environmentalissues, the meeting will be attendedby the environment minister from THEMAINDECISION-MAKING eachcountry andit will beknownas the BODY OF THEEU “Environment Council”. The nine Council configurations are:

Commission that makes proposals. The Council can ' GeneralAffairs andExternalRelations; The Key Role of the Council modify the proposals beforeadopting them. ' EconomicandFinancialAffairs (ECOFIN); The EuropeanParliament as well as the Council of the ' JusticeandHome Affairs (JHA); EuropeanUnion wereset upby the founding treaties The Council consistsofone government minister ' Employment,SocialPolicy,HealthandConsumer in the 1950s. The Council of the EU is the main deci- from eachMember State. Although thereisjust one Affairs; sion-making body.It represents the member states, Council,different groups of ministers meet depend- ' Competitiveness (InternalMarket,Industry and anditsmeetings are attendedby one minister from ing on what the topicis being discussedat the Research); eachof the EU´snationalgovernments. weekly meeting. Eachminister is empowered to ' Transport,Telecommunications andEnergy; commit his or her government andis accountable to ' Agriculture andFisheries; The Council of the EU has the main role in agreeing their ownnationalparliamentsfor decisions taken ' Environment; legislation,although in recent years this hasbeen in the Council. ' Education,YouthandCulture. sharedmoreandmore with the Parliament under the co-decision procedure.When the Council actsas The Nine Council Configurations Eachminister in the Council is empowered tocom- alegislator,in principle it is the European Depending on the matter under discussion, the mit his or her government.That means the minis-

8 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES EU News

ter´ssignature is the signature of the whole gov- ernment.Moreover,eachminister in the Council is THE EUROPEAN COUNCIL answerable tohis or her nationalparliament and to the citizens that parliament represents, which ensures the democraticlegitimacy of the Council´s THEEUCOUNCILDEFINES POLITICAL decisions. GUIDELINES OF THEEUROPEAN UNION Six Key Responsibilities of the Council S ONYA P LANITZER The EuropeanCouncil brings together the heads E DITOR E UROPEAN A FFAIRS The Council has the following six key responsibil- of stateorgovernment of the EuropeanUnion and EUROPE @ EMCEUROPE . COM ities: the President of the Commission. It defines the Topass Europeanlaws. Asabove-mentioned ' generalpoliticalguidelines of the EuropeanUnion. the Council legislates jointly with the European The EuropeanCouncil meetsat least twice yearly pare the workof the Council, with the exception Parliament; (in practice,four times yearly,andsometimes if of most agriculturalissues, whichare handledby Tocoordinate the broad economicpolicies of ' necessary more), usually in Brussels. the SpecialCommittee on Agriculture.“COREPER” the member states. This coordination is carried is assistedby anumber of working groups,made out by the economicandfinanceministers, The EuropeanCouncil provides the impetusfor upofofficials from the nationaladministrations. who collectively form the ECOFIN Council; the major politicalissues relating toEuropean Toconcludeinternationalagreementsbetween ' integration:amendments to the Treaties and The ‘Presidency of the Council’rotates every six the EU andone or morestates or international changes to the institutions,declarations on exter- months. Inother words,eachEU country in turn organisations; nalrelations in the context of the common foreign takes chargeof the Council agenda andchairs all Toapprove the EU budget,jointly with the ' policy andsecurity,etc.But itsguidelines anddec- the meetings for asix-monthperiod, promoting EuropeanParliament; larations are not legally binding. Tobeput into legislativeandpoliticaldecisions andbrokering Todevelop the EU Common Foreign and ' effect, they must follow the routine procedure compromises between the member states. Security Policy (CFSP); through the EuropeanParliament and the Council Currently Austriachairs the EU.InJuly,Finland will Tocoordinatecooperation between the nation- ' of the EuropeanUnion –followed wherenecessary take over the EU Presidency until December 2006. alcourtsandpoliceforces in criminalmatters. by implementation at anationallevel. The Presidency is assistedby the General Most of these responsibilities relate to the Article 4of the Treaty on the EuropeanUnion says: Secretariat, whichpreparesandensures the “Community”domain –for example:areasof “The EuropeanCouncil shall provide the Union smoothfunctioning of the Council’s workat all action where the member states havedecided to withnecessary impetusfor itsdevelopment and levels. pool their sovereignty anddelegatedecision-mak- shall define the generalpoliticalguidelines there- ing powers to the EU institutions. This domain is of.” In 2004,Javier Solana wasre-appointedSecretary- the “first pillar” of the EuropeanUnion. However, Generalof the Council. Heisalso High the last tworesponsibilities relatelargely toareas Organisation of Work in the Representativefor the Common Foreign and in which the member states havenot delegated Council :The COREPER Security Policy (CFSP),andin this capacity he their powers but are simply working together.This InBrussels,eachEU member statehasaperma- helps coordinate the EU’s actions on the world is called, “intergovernmentalcooperation”andit nent representation to the EuropeanCommunity. stage. Under the new constitutional treaty, the covers the secondand third“pillars”of the This representation representsanddefendsits High Representative wouldbereplacedby anEU EuropeanUnion. nationalinterest at EU level. The head of eachrep- Foreign Affairs minister.The Secretary Generalis resentation is,in effect,his or her country’s assistedby aDeputy Secretary-General,in charge ambassador to the EU. of managing the GeneralSecretariat.

These ambassadors (also knownas“permanent Summary representatives”) meet weekly within the Wenow haveanoverview of the “European Permanent Representatives Committees – the Council”, the “Council of the EuropeanUnion”and “COREPER”. The role of this committee is topre- last but not least the “Council of Europe”. Three *

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 9 EU News

* different institutions whose roles should not bemixed up:The EuropeanCouncil is,as abovementioned, the HeadsofStateorgovern- ment of the EuropeanUnion and the President of the Commission. The role of the EuropeanCouncil AUSTRIA ASSUMES is crucial,but differs to that of the Council of the EuropeanUnion, whose members are ministers from the Member States. The Council of the EU PRESIDENCY EuropeanUnion exercises the power conferredon it by the Treaty,subject toreview by the European SERVICESAND WORKING-TIME DIRECTIVES Court of Justice,andit adoptsCommunity legal instruments. Finally, the Council of Europe, which POSECHALLENGESFOR THE is describedon page twelve,is distinct from the EuropeanCouncil,aninternationalorganisation RED-AND-WHITESTRIPED EU PRESIDENCY outside the EuropeanUnion, whichdeals with education,culture andaboveall the protection of humanrights. It currently has46 members. S ONYA P LANITZER

E DITOR E UROPEAN A FFAIRS

EUROPE @ EMCEUROPE . COM

HealthPolicy Goals The proposedservices directiveislikely topres- ent aneven greater challenge. The main bone of OnJanuary 1, 2006,Austria succeeded contention asregards this directive, whichpropos- Britain as President of the European es toregulatecross-border competition in servic- Council, with the Finns set to take the Notwithstanding these positivedevel- es,is the country of origin principle. Under the opments,Austria will have tolead helm when the six-month termexpires. proposal,it is envisaged that companies offering some negotiations on the details of their services across the EuropeanUnion wouldbe During the Presidency,Austrianministers the financialframework. The subject to the lawsoperating in their country of and civil servants will lead roughly 2,000 Presidency must also address the out- origin. Many critics,including asignificant number meetings bothat home and in Brussels. standing issueof the draft of Member States andMEPs,reject this principle FederalChancellor Wolfgang Schüssel,his Constitution for Europe. Other major on the grounds that it will increase competition Foreign Minister,UrsulaPlassnik,and obstacles include the working time from low-wage economies andintensify the prac- directiveand the proposeddirective other ministerialcolleagues will become ticeofsocialdumping. on the provision of cross-border serv- the publicfaceof the EU in International ices. Solving the ongoing dispute In the areaof healthpolicy Austria’s priorities will Affairs.Inconjunction with the about the working time directive be women’s healthand the fight against type-2 Commission, the Parliament and the other shouldprovedifficult.Under the direc- diabetes. The dramaticincrease in the incidenceof 24Member States,Austriamust try to tive, whichdates back to1993, week- diabetes,specifically type-2,haspushed the issue find compromise solutions tooutstanding ly working times, when averagedout to the top of the medicalandhealthpolicy agen- issues. over afour-monthperiodmay not das. Aconferenceondiabetes in Vienna will exceed48 hours. The European declare waron the disease. The priorities in the Parliament andseveralMember States areaof women’s healthare toimprovepublic Despite these challenges, the Presidency will have are now pressing for the removalofaseries of awareness of endometriosis and tofocuson the fewer tasks tomaster thaninitially anticipated derogations whichhavebeen in placesince the issueofosteoporosis. Inaddition, the Austrian due to the success of the British Presidency in directive’sintroduction. Inreturn,it is expected Presidency hasmadeacommitment todraw upa hammering out afinancialframeworkfor the peri- that the four-monthcalculation period will be comprehensiveEU alcohol strategy andadopt the odfrom 2007 to2013 andaforgedagreement on extended to12 months. Although opposition to the WHO frameworkconvention on tobaccocontrol. the chemicals directiveknownas“Reach”,a proposalisledby Britain and the new Member Moreinformation on the AustrianEU Presidency is sourceoflong-standing controversy. States,it also includes Austria. available at:http://www.eu2006.at/en/

10 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES EU News

gy paper.Due tobecompletedby the endof the year, this aims toset the frameworkandprovide amorecoherent approach toEU publichealth activities.

R ORY W ATSON

EU C ORRESPONDENT While fully accepting that the provision andman- agement of healthcare remains anationalrespon- RORYWATSON@ SKYNET. BE sibility, this will emphasise whereUnion activity canbring added value. This is notably the case in developing the EU’s capacity torespond tohealth emergencies. Here, the recently established EuropeanCentre for Disease Prevention and PRIORITIES OF THE Controlbasedin Stockholm, whichishelping to put in placeastructure for handling pandemics, AUSTRIAN AND FINNISH will haveakey role toplay.The strategy paper will also examine how to tackle inequalities in health treatment andhow tostrengthen the Union’s role PRESIDENCIES in internationalhealthorganisations anditsrela- tions withnationalhealthsystems. The Austrianand Finnishgovernments havealready established the priori- ties for their twoPresidencies as they steer EuropeanUnion business Further measures tohighlight the dangers of throughout the year.Whether they manage toachieve their objectives will tobaccoloom largeon the Commission’s agenda. depend not just on their diplomatic skills,but alsoon the willingness of the It will launchanew awareness programme aimed at the young,deglamourising the practiceof EuropeanParliament and EU governments to strike compromises,particular- smoking,andis considering setting upa ly on legislativeproposals.Vienna will haveits workcut out if it is to reach EuropeanYouthParliament todiscuss tobacco agreement on the provisions of an updated working time directive. As nego- control. tiations between employment ministers in Brussels shortly beforeChristmas demonstrated, thereis ahuge gulf between thosecountries who wish to Member states whichhavefailed tofully imple- retain the opt-out from the 48-hour week and those that wish tophaseit out ment EU legislation banning tobaccoadvertising, that came intoeffect last August,facelegalaction. eventually. The main culprit is Germany.Berlin tried unsuc- cessfully topersuade the EuropeanCourt of Surprisingly,alargepart of the complex negotia- market in this area.The probable outcome should Justice todeclare the legislation illegalandhas tions werefilmedandbroadcast live tomediaand become clearerinmid-February when the still not transposed the EU directiveintonational the public, sitting elsewherein the building,and EuropeanParliament will voteon the draft text.At law.But some countries –Italy,Spain andHungary providedafascinating insight into the way deals stake,from the medicalpoint of view,is whether –are believed tobeflouting the new rules by are normally put together behindcloseddoors. healthservices shouldbeexcludedfrom the allowing advertising at FormulaOne racing events. But,even with the evident goodwill that existed scope of the legislation. The Parliament is split Others,suchas the CzechRepublicandPortugal, on all sides, the gapproved too wide tobridge. If over the issue. The Left basically supportsexclu- havestill not notified the Commission of the that remains the case, then behaviourin this area, sion. The Right acceptssuchasolution for public measures they have taken toimplement the legis- particularly on on-call time, will bedetermined healthservices,but believes that privateservices lation. Organ transplantation is another area moreby rulings from the EuropeanCourt of shouldbecovered. where the Commission is exploring the possibility Justice,asin the past, thanby legislation agreed of further EU action. Union rules already cover by Europe’s politicians. The results,either way, will haveimplications for blood, human tissueandcells. The Commission is the healthsector.The EuropeanCommission, now examining issues suchas the donation and The twogovernmentsmay havegreater success whichhasdrawn upitsownpublichealthpriori- trafficking of organs andintends to table alegisla- on the services directive,anambitiouspieceof ties programme for 2006, will have to take this tiveproposallater this year toguarantee their legislation that aims toliberalise the cross-border intoaccount asit finalises a wide-ranging strate- quality andsafety.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 11 EU News POWER OF LEGISLATION PRIORITIES OF THEAUSTRIAN Inother fields the Council makes itsdecisions by QualifiedMajority Voting. EachMember Statehas ANDFINNI SH PRESIDENCIES aspecificnumber of votes (see below), whichis related to the sizeofitspopulation. Aqualified S ONYA P LANITZER majority will bereached, if amajority of member E DITOR E UROPEAN A FFAIRS states approveandif aminimumof 72.3 %of EUROPE @ EMCEUROPE . COM votes are cast in favour.

FromNovember 1, 2004, the totalnumber of votes The power tolegislateis shared by the Council and the EuropeanParliament.Inmost is 321. The number of votes eachcountry cancast situations,Europeanlaws aremade by aco-decision procedure. This means that the is asfollows: Council and the Parliament jointly adopt proposals for legislation that havecome from ' ' GGermermaannyy,F,Frraannccee,I,Ittaallyy aanndd tthehe UKUK 229 9 the EuropeanCommission. The Council and the Parliament canmake amendments to ' ' SSppaainin aanndPdPololaanndd2727 NNeettherlherlaanndds1s13 3 the legislation under this procedure. However, therearecertain important areas,for ' ' ' ' BBelgielgiuumm,C,CzzeecchhRRepepuubblilic,c, GGrereeeccee, , example, tax legislation, where the Parliament may only giveanopinion as to whether HHuungngaarryy aanndPdPorortutuggaal1l12 2 aproposed pieceoflegislation canbecome law.Also, the Council only acts,as a rule, ' ' AAuussttririaaaanndSdSwweeddenen 110 0 on aproposalfrom the Commission,and the Commission normally has responsibility ' ' DDenmenmaarkrk,I,Irerellaannd,d, LLiitthhuuaaninia,a, SSlolovvaakikia a for ensuring that EU legislation,onceadopted,is correctly applied. aanndFdFinlinlaanndd7 7 ' ' CCyyprpruuss,E,Essttonionia,a, LaLatvtviia,a, LLuxuxemembboouurgrg aanndSdSlolovvenieniaa4 4 How the EU Makes Decisions procedure,asinall others,if the Council amendsa ' ' MaMallttaa3 3 Commission proposalit must doso unanimously. Ingeneral,it is the EuropeanCommission that pro- poses new legislation,but it is the Council and Modernising the System with the The assent procedure means that the Council has to Parliament that pass the laws. Other institutions Constitution obtain the EuropeanParliament’s assent beforecer- andbodies also haveroles toplay. The EU is growing bigger andbigger.But the deci- tain very important decisions are taken. In this case sion-making system hasevolvedover the course of the Parliament cannot amendaproposal–it must The rules andproceduresfor EU decision-making half acentury and wasoriginally designatedfor a either accept or reject it.Acceptance(“assent”) are laiddownin the treaties. Every proposalfor a community of just six nations. The EU now has 25 requires anabsolutemajority of the votecast. new Europeanlaw is basedon aspecific treaty member states anditsmembership will increase article,referred toas the “legalbasis”of the pro- further in the years ahead.The decision-making Finally,co-decision is now usedfor most EU law- posal. This determines whichlegislativeprocedure system thereforeneedssimplifying andstreamlin- making. In the co-decision procedure,Parliament most befollowed.The three main proceduresare ing. Toavoidparalysis,most decisions will have to does not merely giveitsopinion; it shareslegisla- “consultations”,“assent”and“co-decision”. be taken by “qualifiedmajority voting”rather than tivepower equally with the Council. If the Council requiring eachindividualcountry toagree. and the Parliament cannot agree on apieceofpro- Under the consultation procedure, the Council con- posedlegislation,it is put beforeaconciliation sults the Parliament as well as the European The proposedConstitution agreedby the European committee,composedof equalnumbers of Council EconomicandSocialCommittee (EESC)and the Council in 2004 tackles these questions head on. andParliament representatives. Once this commit- Committee of the Regions (CoR). The Parliament It spells out muchmoreclearly thaninprevious tee hasreachedanagreement, the text is sent has three opportunities: treaties what the EuropeanUnion is and whereit onceagain toParliament and the Council so that 1. Toapprove the Commission proposal; is going. It laysdown the new rules for more they canfinally adopt it aslaw. 2.Toreject it,or; streamlineddecision-making. It is due tocome 3.Torequest amendments. intoforcein 2006,but first it has tobeapproved Different Ways the Council by all 25member countries –insome cases by ref- If the Parliament asks for amendments, the Makes Decisions erendum. Meanwhile the situation is at astandstill. Commission will consider all the changes the Thereare different ways that the Council makes its While some member states approved the Parliament suggests. Ifit acceptsany of these sug- decisions. Aunanimousdecision is requiredin Constitution, the referenda in some countries –as gestions,it will send the Council anamendedpro- important areas,for example,common foreign and in Franceorin the Netherlands-ended withaneg- posal. The Council examines the amendedpropos- security policies and taxation. Eachmember state ativeresult.There will now beaperiodof reflec- alandeither adoptsit or amendsit further.In this hasa votein those areas. tion,assome politicians havestated.

12 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Industry News Siemens LaunchNew Philips iSitePACS “Best in Radiography System KLAS: PACS Category” Siemens MedicalSolutions recently launchedAxiom Aristos FX Plus, the Siemens LaunchNew new radiography system withintegrat- Radiography System edflat detector (FD) technology.

AgfaHealthCare Awarded The new radiography system covers a Philips iSitePACS “Best in Extensions on TwoContracts widerange of examinations including KLAS: PACS Category” the head, thorax,abdomen,pelvis and extremities or in the traumaroom. Rogan-Delft AppointsRAD Philips MedicalSystems,adivision of Benefitsof the new system allow the Systems asDistributor RoyalPhilips Electronics,announced that user tocontrolall system movements Philips iSitePACS wasnamed“Best in via wireless remotecontrol,allowing HologicAnnounceQuarterly KLAS PACS”in the 2005Top 20 Year-End them tocontrolcollimator settings, Results Best in KLAS Awardsreport from KLAS patient table movementsas well asX- Enterprises. This is the thirdconsecutive ray tubeanddetector positions. BarcoLaunches 2MP Colour “Best in KLAS”ranking for iSite. Display System for PACS Moreover, the remotecontrolis The report categorises each vendor prod- equipped withasafety feature that uct intoamarket segment wherelike PlanarAnnounces First produces anaudible warning if it is Quarter 2006 FinancialResults productsare comparedandranked more than15metresaway from the basedon datacollectedbetween system –ensuring safe return of the October 15, 2004andNovember 15, device. Another user-friendly feature is 2005asreportedby professionals from the new detector housing for easy grid integrateddelivery networks,clinics,and management. acutecare facilities. KLAS evaluates ven- dors by collecting aseries of product and vendor evaluations covering 40 perform- anceareasfrom these healthcare provider organisations.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 13 Industry News XS PACS solution in the Californiaand Nevada territory. compared withnet income of Commenting on this appointment,Bart $4,574,000,or $0.11 per dilutedshare, Hendriks,VicePresident of Rogan-Delft in the first quarter of fiscal 2005. The said“Weare happy tobe working with improvement in quarterly earnings pri- RAD Systems,asupplier of fully inte- marily reflects the increase in product grated workflow solutions. The combi- sales of Seleniadigitalmammography AgfaHealthCare Awarded nation of ourPACS systems,designed systems in the current quarter ascom- Extensions on TwoContracts tomeet the workflow requirementsof pared to the first quarter of fiscal the most demanding radiology centres, 2005. AgfaHealthCare announced that it has with the distribution networkofRAD been awardeda two-yearextension on Systems will strengthen ourpresence twomulti-sourcecontractsby the andreputation in these important grouppurchasing division of Premier, regions.” Inc.,Premier Purchasing Partners,L.P., toprovidefilm andmedicalimagers to the alliance's nearly 1,500 member hospitals. BarcoLaunches 2MP Colour Display System for PACS Withacombined valueofapproxi- mately $150million a year, the con- tractsmean that AgfaCorporation will Barcohasintroducedanew member act asaprovider of acomprehensive toitsfamily of PACS display systems. assortment of medicalfilm and Nio Color 2MP is aflexible display sys- HologicAnnounceQuarterly imagers. tem that offers clinicalconfidenceand Results dependable performancefor amulti- tudeofmedicalimaging applications, Hologichaveannounced the following including 3DPACS, ultrasound, financialhighlightsof the quarter: orthopaedicimaging,cardiology,oph-

' Revenues of $88 million thalmology,nuclearmedicine andPET. ' Backlog of $140 million It featuresimprovedgrayscale image First quarter fiscal 2006 revenues quality,colourand 3Drendering per- Rogan-Delft AppointsRAD totaled$87,956,000,a 33%increase formance. Barco's Nio Color 2MP dis- Systems asDistributor when compared torevenues of play system hasrecently receivedFDA $66,176,000 in the first quarter of fis- 510 (k) clearancefrom the U.S.Food Rogan-Delft hasannounced the cal 2005. For the first quarter of fiscal andDrugAdministration (FDA). appointment of RAD Systems asoffi- 2006,Hologicreportednet income of cialdistributor of Rogan-Delft OnLine $5,716,000,or $0.12 per dilutedshare,

14 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES MANAGEMENT IN RADIOLOGY CONFERENCE 2006

9 TH A NNUAL M EETING October 5– 7, 2006 Submission of abstracts Budapest,Hungary invitedbeforeAugust 20, 2006 Venue:Hotel Sofitel**** LocalOrganiser: Visit www.ewgmr.org Prof.Andras Palko,HU Prof.AdamMester,HU Registration fee waived for participants with Organising Secretariat: accepted abstracts. Antonio Santoro,IT Junior Radiologists (under 35):no fee required.

MIR represents adedicatedarenafor the discussion of Topics include: servicedelivery andmanagement issues specifically tailored Radiology Department Organisation to the needs of radiologists in Europe. Teleradiology,RIS-PACS Interaction This annualmeeting is acrucialdatein the schedule of any radiologist,in charge of running adepartment andinterest- ElectronicManagement of RadiologicalData edin management issues. AcademicRadiology:Teaching &Research

Organizedby Subcommittee on Management of the Leadership EuropeanSociety of Radiology. TurfBattles &Partnership Strategies Board: Chair GeorgBongartz (CH),AssignedChair Nicola Emergency Radiology Strickland(UK),Oliver Clement (F),Paolo Pavone (IT), Standards JohanBloem (NL),Sergei Nazarenko (E),Secr.POC ex officio Peter Pattynama(NL),Chair POC ex officio MedicoLegal Bruno Silberman(F),Henrik S.Thomsen (DK) Quality Issues

I ncooperation withAUR-EAssociation of University Change Management Radiologists in Europe. GeneralManagement:Teaching &Reflection Cover Story Teleradiology

TELERADIOLOGY THE WAYFORWARD

DEFINING OURNEW ROLE

Teleradiology is now widely usedfor the transfer of images, andfor providing reports and secondary advice. It has the potential toprofoundly change the way radiology is prac- ticedandmay well alter not only the established structure of radiology,but also the training of radiologists.The tradi- tionalmodel of the radiologist working in apracticeor hos- pitalanddealing with the cases requestedby localclinical specialist colleagues is being partly replacedby reporting undertaken in distant centres withcommunication between radiologist andclinicianby email or telephone. Work under- taken out of the normal working day is reportedby teleradi- ology services, whichmay beprovidedin the US,Europe,or beyond.

Asubstantialnetworkofreporting is now establishedin tions being some of many additionalroles. Radiologistsmust Scandinavia, providing specialist reporting tosmall centres also work together toresearchnew technologies and toapply that donot havearadiologist or who requiresecondopin- them appropriately in the clinicalsetting. ions. In the UK, the government hasdirectly contractedand purchasedMRimaging andreporting services that are being Conclusion providedfrom outside the country without any involvement It is therefore vitalfor the patient that their images donot of localradiologists, thuschanging dramatically the consul- become acommodity and that radiology asaclinicalspecial- tation process andrelationship withlocalclinicalcolleagues. ty,does not disintegrate. The EuropeanAssociation of AUTHOR Radiologists(EAR)inconjunction with the radiology section P ROF .I AIN M C C ALL The potentialfor the development of largereporting centres of the Union of EuropeanMedicalSpecialistshasproduceda E DITOR- IN-C HIEF withgroups of radiologists undertaking andbeing trainedin series of guidelines for the use of teleradiology, toensure E I C@IMAGINGMANAGEMENT. ORG alimitedrange of examinations is realand will completely that the patient receives the best quality of servicefromradi- remove the clinicalinvolvement andbroad knowledge and ology.These emphasise the importanceof the relationship of flexibility of the present generation of radiologists. the radiologist with the patient and the treating clinician. They also stress the importanceof the localradiologists Changing Working Practices being closely involved with the teleradiology serviceso that The present view that radiology is best practicedclose to the patients’ imaging care is managedin acoordinated way and patient and that radiologistsprovideamuch wider function that previous testscanbecomparedand the overall results thansimply reporting,is being challenged.Analysis of radio- discussed with the patient and the clinician. It is vital that logists’ time and workin the Netherlandshasshown that hospitalmanagers integrate teleradiology fully into their reporting occupies less than50%of the workload, withmany onsiteimaging services for patient management,film storage other roles including justification of the examination,choosing andlong term care and use suchservices toenhance their the most appropriateimaging,comparing previousexamina- ownservices wherenecessary andnot asacost cutting tions with the present test,discussing results with the referring measure bypassing and undercutting the corelocalservices. clinicians who are usually well known to them,participating in multidisciplinary meetings andadvising on follow-upinvestiga-

16 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Cover Story Teleradiology ❚❚❚

Teleradiology is becoming animportant tool in the practiceandquality-management of healthcare worldwide,in part due to the ever-increasing shortage of radiologists, to the number of areas sparse- ly populatedby radiologists,andbecauseofalackoflocally available secondopinions andexpert- ise. Given the fact that the EuropeanCommission views radiology as a serviceindustry,it is evident that agoalof the EU is that medicaldiagnostic services shouldbeavailable without restrictions throughout the entireEU at a similar level. Teleradiology has been technically restrictedby point-to- point connections andmanual sending of patient information between participating organisations. This cannow be replacedby regional solutions for PACS covering the whole community,link directo- ries (healthcare record summaries) whichare the ‘glue’ between enabling the viewing of images from anotherorganisation or region andelec- tronicmarketplaces, where you candeliver consultation services flexibly.Thus, resources andpatient information canbe sharednation- andEurope-wideand the processes or carepathways canbeintegrat- edin a seamless and secure way.

NEWEUFRONTIERS FOR TELERADIOLOGY The Golden Rules:Guaranteeing GoodPractice The new serviceenvironment or digital workplace will be the timely interpretation of emergencies 24/7,from any loca- cementedby: tion andany hospital,increasedflexibility of radiologists, ' Co-operation between radiologistsindifferent EU countries; functioning asa virtualextraradiologist,sub-specialist inter- ' Establishment of commercialagreementsfor consulting, pretation options andnew opportunities for continuing med- providing,andsub-contracting services within the EU and icaleducation. withcentresoutside the EU; ' Differentiation between the physicalspaces whereradio- Challenges toCome for logicaldiagnosticexaminations are performedand those Teleradiology in Europe in which the examinations are evaluatedandreportedon; How can weachieve this ‘utopian’ vision for the future of ' Guaranteedservice without territorialconstraints,recog- imaging services in Europe? Firstly,anumber of practical nising the mobility of the population in the world today; issues need tobereviewed.Legalissues abound, particular- ' Elimination of language barriers that limit the offer/pur- ly in the security andconfidentiality realm,for example; chase of services; guarding against misdiagnosis; the legality of having adigi- ' Legalcompatibility between interregionalor trans-national talsignature on bothrequest forms and the finalreport in all services toensure sharing,security,andconfidentiality of member states; secure licensing of the interpreting radiolo- datarelated to the healthcare process; gist and training management;different legalstructuresin ' Nudging the EU tonot only establish but also enforce every Europeancountry;privacy issues,anddatasecurity standardsfor training andmaintaining competence. while in transfer.

InEurope, the advantages of teleradiology are different to Also, thereare varying levels of radiological training as well AUTHOR those enjoyedin the US;off-hourserviceprovision is not asexperiencewithadvancedmodalities in Europe,and vary-

P ROF .J OHAN G.B LICKMAN suchanattraction,andalso because the threat of malprac- ing levels of standardisation andregistration. This,contrary

C HAIRMAN,DEPT. OF ticeisall but non-existent here. The realopportunity for tel- to the situation in the USA, does not allow for a universal R ADIOLOGY eradiology in Europe is the way it addresses the overflow standardof care withresultant levels of expectations

UMC S T .R ADBOUD, phenomenon. Additionally, the growing EU hasnow incorpo- between clinicians andradiologists. Other disadvantages N IJMEGEN,THE ratedmembers that havemedicaldiagnosticlevels nowhere include the fact that multiple languages exist in Europe that N ETHERLANDS nearaslarge,modern andefficient asin the “Western” couldlead todifficulties withinterpretations of nuances and J.B LICKMAN@ RAD. UMCN. NL world.The benefitsof teleradiology canbesummarisedas intent in any form of communication. *

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 17 ❚❚❚ Cover Story Teleradiology

* How the EU is Advancing through state-of-the-art pan-Europeanimaging services. Teleradiology in Europe Users canrequest teleradiology services by completing a Everything that makes Europe the uniquealliance that it is; structured, multilingualelectronicrequest form and then pro- differences in language,culture,education,etc, are also vide the image data through secure and trustednetworks. reflectedin the barriers that standin the way of full imple- Providers will log in torespond to these requestsand will mentation of teleradiology for everyone. These issues have deliver areport,accompaniedby processed/analysedkey the attention of the governing bodies in Brussels,but answers images. With the aidof e-Image processing,interpreting radi- CONTINUED are not yet clearandfurther attempts tocreateamorecom- ologistsandreferring physicians are better able tomaximize N EW EU F RONTIERS prehensivestandardof training andcare is under way.One of information from CT andMRI exams andcanreadily apply FOR T ELERADIOLOGY these is the eTen project,aninitiative tobring new EU mem- that knowledge todiagnoses, treatment andsurgicalplan- bers intoparity withregards tohealthcare delivery. ning. While sucha vision may seem tobealong way from becoming the new ‘standard’, the rising uptake of teleradiol- This future teleradiology serviceportfolio, whichdelivers ogy across Europe,and the obviousbenefitsfor patientsand imaging-relatedservices in anew way, will consist of e- carers alike,means that teleradiology hasguaranteedaplace Consultation andsecondopinion,ande-Image processing, for itself in the future of healthcare in Europe andbeyond.It analysis andsupport services (e-Archiving ande-Training). remains for those with the power todoso, toensure that The finalgoalin the EU is tooffer patientsinEurope ane- everything is done toresolve the variety of issues that Marketplace where they haveaccess tooptimalmedicalcare remain in itspath.

THE FUTURE OF TELERADIOLOGY

WHYOUTSOURCINGWILL BECOME BIGBUSINESS

Information technology has revolutionised the profes- sion of radiology andnuclear medicine. It has madea filmless department and the viewing of radiologicalexaminations from remotecomputers any- wherein the hospitalor even at home apossibility.Infact, wecannow sendout imaging studies that aremadeduring out-of-officehours tonight-hawk services,locatedinsideor outsideof the country,expecting tofind the full written radiology reports the next morning. Information technol- ogy,in short,is behind the genesis of teleradiology.In this article I will focus on how teleradiolo- gy will profoundly change the way wepracticeour profession,evolving intoanalmost complete outsourcing of radiology services.

bulk of radiology examinations made worldwide. Because of Globalisation: their high-volume throughput, these centres will develop Changing the Way WeWork unmatchedconcentration of expertise andindustry-level Because radiology examinations cansoeasily besent over quality controls (e.g.,by using double or triple readings in high-speedbroadbandconnections toanywherein the world every examination). Teleradiology hubs will become leading at ever reducing costs, thereisnolonger any obligation for centresfor scientificexcellence. the radiology report tobe written by the in-house radiologist in the hospital where the images havebeen acquired.Ina Cost Benefits in Outsourcing globaleconomy, the in-house radiologist is in direct compe- Thereare soundeconomiclaws that predict the rise of the tition withall other suppliers of radiology services world- outsourcing model of radiology services,envisaging a time wide. Economiclaw dictates that this competition will be when these will beoutsourced tocountries where this can won by radiologistsincountries that offer cheapest labour. bedone in amorecost-effective way.Thus,if radiology serv- In these countries, teleradiology hubs will rise,handling the ices are outsourced tointelligent,motivatedand well-trained

18 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Cover Story Teleradiology ❚❚❚

radiologistsinlow-wage developing countries who do the to the specificclinicalneeds. Radiologistscheck whether an workat afraction of the cost,from the macro-economicpoint examination is justifiedandassuch,protect the medicalsys- of view,all will benefit.After all, this means that wealthier tem against self-referrals andmanage workflow andquality countries now haveaccess tocheaper radiology services. The assuranceofimaging departments. Being the imaging con- advantages of outsourcing radiology havebeen recognised sultant to the other clinicians in the hospitalidentifies the by analystsandpolicy-makers alike. ToquoteDanGriswold, “added value” of the radiologist. a tradeanalyst from the CatoInstitute,in Washington DC “Hospitals cansendradiology exams toIndiaandcut the IMAGING CONSULTANCY: TASKS OUTSIDE OF REPORTWRITING cost in half andcontrolspiraling healthcosts.” ' Advising on optimaldiagnostic work-up ' Justification of examinations in individualpatient Inlow-wage countries,entrepreneurs are carefully weighing ' Optimising and tailoring individualexaminations business opportunities,making carefulanalyses of the mar- ' Ad-hocproblem solving e.g. proximity/accountability/responsibility ket and their ownstrengths and weaknesses. Some have Conferencing in multidisciplinary teams:assessing diagnosticimpact of radiology already decided to take the leap,asfor example DrArjun ' Kalyanpur,CEO of Teleradiology Solutions andDr. Ashis report andits therapeuticimpact Dhawad, COO of TeleDiagnosysServices,bothbasedin India, ' Organising workflow in the department who providenight-hawkservices mainly toUS hospitals. ' Quality control Others are likely tofollow suit.These examples show that the business concept is a viable one andalso prove that patients,insurers andgovernmentsin the developed world Diversifying Our Role accept the principles of radiology outsourcing. The main fac- It hasbeen estimated that radiologistsspendon average tors that limit outsourcing are licensing issues andarelative 70%of their working time on imaging consultancy activities lackof well-trainedradiologistsinlow-wage countries. and 30%onreading examinations and writing radiology reports. Although exact dataon time expenditure is lacking, FutureofRadiology Outsourcing clearly, when the task of writing the radiology report is being It is time for radiologists to take the issueofoutsourcing seri- outsourced, radiologistsshouldstress their role asimaging ously anddeal with the relevant issues. For example:How consultants. Infact,strengthening ourrole asclinicaldoctors muchofour work will beinfluenced?How should wedefine withagreater input in the management of individualpatient ourrole in “new”radiology?How will practices change? care will make our workmorechallenging,interesting and Consider these pointsin turn. Dataindicates that more than rewarding. Assuming responsibility for the quality of the 90%ofall radiology examinations couldbeoutsourced.Take, entirediagnosticimaging process also implies that the in- asanexample, the average radiology practiceinThe house radiologist shouldcontrol the quality of the outsourc- Netherlands. CT,MRI andconventionalradi- ing radiology service. Therefore,it is crit- ographs, that canbereadily sent for ically important that outsourcing is a remotereporting,make up 23,16 and 35% IT is behind the servicebetween the in-house radiologist of totalproduction,respectively, when genesis of and the remoteradiologists writing the expressedin a time-relatedproduction reports. parameter.Ultrasoundexaminations, teleradiology accounting for 19% of production,couldbe Inevitably,problems in coding andbilling sent out for remotereporting in practices where technicians will occur. Most reimbursement systems are basedon afee- perform the examinations andimages are reviewedat alater per-report basis,anddonot take intoaccount consultancy time by the radiologist,asiscustom in the UnitedStates. In activities. Historically, this madesense because radiology AUTHOR fact,only 6%ofradiology production in vascularandinter- reporting andclinicalactivities involvedin areport were P ROF .P ETER M.T. ventionalradiology are exempt from potentialoutsourcing. done by anindividualradiologist/group. Outsourcing physi- P ATTYNAMA, cally separates these activities –but reimbursement is still R ADIOLOGIST When defining ourrole in light of radiology outsourcing,it given for writing the report only.It is therefore urgent to S ECRETARY G ENERAL, shouldbeclarified that aradiologist’s jobentails more than adapt the coding andbilling system, to take intoaccount the UEMS R ADIOLOGY S ECTION making the radiology report.Anentirechain of processes has activities of radiologistsoutsideof writing reports. It is in our E RASMUS U NIVERSITY taken placebefore the radiology examisactually ready for interest and tomake ouradded value visible toourcol- M EDICAL C ENTRE, reporting. Also, the relevanceoffindings in the radiology leagues,patients, the generalpublic, and toreimbursement R OTTERDAM,THE report must becarefully analysed.These tasks are the agencies. N ETHERLANDS responsibility of the radiologist andare part of his “imaging P . M . T . PATTYNAMA@ consultant”function (see table below). Wemust expect resistance to these changes, whichhavein ERASMUSMC. NL Inpatient care,radiologistsguard the patients’ individual generalserved the interest of radiologists well. Especially now, diagnostic work-upinitsentirety and tailor the examination we witness ashortage of radiologistsagainst aback- *

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 19 ❚❚❚Cover Story Teleradiology

Conclusion Insummary, weasradiologistsshouldfirst andforemost accept the idea that radiology outsourcing will likely become arealissuein the nearfuture.Weshouldaccept that most * groundof steadily rising consumption of radiology of ourradiology reportsmay beproducedby outsidecon- services in many countries. At afixedhigh priceper radiology tractors in low-wage countries. Toaddress this, weneed to report, these factors tend toincrease the income of individual emphasise ouradded value topatient care by strengthening radiologists. But the very same elementsofrising demandfor ourrole asimaging consultants. Weshouldsafeguard the CONTINUED radiology,rising costsandshortage of radiologists will favour quality of the entirediagnosticimaging process, which T HE F UTURE OF radiology outsourcing. When outsourcing really takes off, the includes controlling the quality of the outsourcedreporting. TELERADIOLOGY priceofaradiology report will fall sharply and the radiologist Outsourcing shouldbeaservicebetween radiologists. We depending on afee-per-report scheme will behurt by adou- shouldreconsider the appropriateness of the fee-per-report ble whammy:he is allowed toproduceonly alimitednumber reimbursement scheme. This is aresponsibility shared of radiology reports,and this at asharply decreased unit price. between individualradiologists,nationalradiology societies andsupra-nationalorganisations suchas the ESR and the UEMS in Europe,and the ACRin the US. TELERADIOLOGY IN INDIA

INDIA AT THEFOREFRONT OF IMAGINGOUTSOURCING

The potential to use technology todeliver medical services across large distances has always excit- ed visionaries and technology-orientedhealthcareprofessionals.The diversenatureof medicaldata, from records toimages andlive teleconsultations amongst others, results in a wide range of volume that must bemanaged.Inaddition, remotehandling and transmission of medicaldatamust facechallenges suchas medico-legalimplications, data security,quality and turnaround time. This article focuses on theseissues andhow they have resultedin the growthof telemedicine andin turne-Radiology services in India.

Conventionalimaging modalities like Ultrasonography (USG), age requirementsfor archiving and transmitting these images ComputedAxialTomography (CT),andMagneticResonance are currently in tetrabytes and will eventually grow to Imaging (MRI)producedataof the order of 50 Megabytes petabytes (1024*1024*1024*1024bytes). Users are also seek- (MB)per study.Oflate therehasbeen anexplosion of 3D ing storage solutions that providefaster response and imaging modalities like Angiographies,MultiPlanar increaseddataavailability across networks. Producing asys- Reconstruction,MaximumIntensity Projections (MPR/MIP) tem that fulfils user requirementsanddatahandling consti- and 3DReconstruction for AnatomicalEvaluation. The stor- tutes amajor challenge.

20 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Cover Story Teleradiology ❚❚❚

Security Issues takes care of medico-legalaspectsofoutsourced work. The In the US andEurope,guidelines suchasHIPAA andIHE are experiencegainedfrom the US market hasresultedin many in place toprotect patient healthcare information. Inaddi- firms expanding their services toEurope,Africa and the tion,patient datais also protectedin terms of procedures Middle East.On the other handIndianhospitals who could suchasauditsandsecurity plans,disaster recovery and not sourceUS-certifiedradiologistsare doing pre-processing backup,andsecurity in the form of authentication and for their US counterparts. encryption. DICOM standardsare aboon todatamanage- ment.Commandsbetween DICOM systems are first associat- IndianTeleradiology:Fantasy Vs. ed, negotiated, acknowledgedandonly then transferred to Reality routable destinations. Guidelines regulateconformancestate- The foremost challenge is tohaveUS board-certifiedradiol- mentsfromeach vendor of medicalequipment on support- ogistsin the reporting panel toaddress medico-legalimpli- edfunctionalities,SOP-classes and transfer syntax.DICOM cations, whichensuresconfidencein the offshoreradiologist takes care of localnetworkcomplianceanddictates security who comes up with the report.Without this, the role of over the internet withfurther measures,for example,Public reporting centresisreduced to that of merely anight-hawk Key Infrastructure (PKI),Secure SocketsLayer (SSL)protocol service, whichisnot productivein terms of money or growth and128-bit encryption,and the VirtualPrivateNetwork prospectsin the long-term. (VPN). The following table gives some of the commonly avail- able networks and time taken to transfer the same 25MB Though the Indian training system produces approximately study over the network. 120 radiologistsa year, tomotivateanIndianradiologist to moonlight in the outsourcing industry requires afinancial NETWORK NAME SPEED (BITS/SEC)STUDYTIME andstable career pathcompared to working in the private LocalAreaNetwork(LAN) sector or engaging in independent practice. Toensure this, teleradiology businesses need tomature intocredible and Gigabit/Fiber optic1,024M2 seconds lasting models with the necessary checkpointsbuilt in to ATM155 M12 seconds meet changing industry andmarket trends. Apart from HIPAA Fast Ethernet100 M20 seconds regulations, the US healthcare industry faces numerousother WideAreaNetwork(Internet) regulations. The AmericanCollege of Radiology hascome up T11.5 M22 minutes with the recommendation that only radiologists withmal- Broadband/ISDN 256 K2.15 hours practiceinsuranceshouldbein the growing teleradiology business. Also, thereisamove tolimit the number of reports Modem 56 K10.0 hours aradiologist cangenerateper day.All these regulations impact teleradiology. Background Since the early tomid1990s,outsourcing hasbeen develop- Finally, the availability of manpower andITinfrastructure is ing at arapidrate. The next decade witnessedanexplosion concentratedin few major cities developing asIT hubson of IT enabledservices that had animpact on the healthcare the globalmap. Bangaloreisnow knownas the IT capitalof industry.The Indianspaceresearchorganisation,by leasing Asia.This means growthof the outsourcing industry is con- itscommunication satellites,heraldedanew erain telemed- fined to these cities only.Todisseminatebusiness, there icine. This positive trendin IT andhealthcare allowedUS- shouldbematching growthinother partsofIndiaas well. AUTHORS basedradiologists tooutsource work toIndiadue toashort- This calls for coordinatedeffortsbetween variousdepart- D R .JR R AJA ( SEE PICTURE) age of radiologistsin the US andperceivedcost and time mentsandprofessionals ranging from politicalgoverning D EPARTMENT OF I NTENSIVE benefits. Hencemost teleradiology services presently provid- bodies in the states,ITand telecom sectors andhealthcare C ARE M EDICINE, edin Indiaare for US counterparts. Also some Indianhospi- professionals. W HITTINGTON H OSPITAL tals provide teleradiology asapreliminary reporting service NHS T RUST,HIGHGATE for emergency scans,referred toasanight-hawkservice. Conclusion H ILL,LONDON,UK The pathahead, though riddled withobstacles,is heading in ICUDR@ DOCTORS. ORG . UK Why outsource teleradiology to the right direction. Due togrowthinprivatehealthcare, the India? advent of medical tourism andinternationalhealthinsur- K ASI V ISWANATHAN

Apart from the availability of trainedradiologistsinsufficient ance,alternativebusiness models relying on localneedsand CEO, P ICAV OX numbers andITfirms, the time zone advantage for US-based demandsare appearing in the horizon whichoffers a way out T ECHNOLOGIES,INDIRA firms hasput Indiaon the globalmapfor the outsourcing with the infrastructure if the outsourcing business slows. In N AGAR,BANGALORE 38, industry.This guarantees good turnaround time, whichin ouropinion the wider availability of WIFI, broadbandservic- I NDIA KASI@ PICAVOX . COM turn translates intocost-effectiveness. Many leading teleradi- es,mass storage solutions andaffordability will remarkably ology firms haveUS board-certifiedradiologistsas their alter the business of clinicalprocess outsourcing in India angel investors or CEOs. This ensuresHIPAA complianceand within the next two to three years.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 21 ❚❚❚ Cover Story Teleradiology

‘Therearemany issues yet tobeaddressed tofacilitategrowthandgood practicein teleradiology.The ECRoffers the opportunity tolearnmore about theseissues and topromote the dissemination of information,by holding a special session on teleradiology at their forthcoming conference in Vienna, Austria.As Chair of this session,I will provideanoverview of how teleradiology has changed the faceofimaging workflow in Europe. This session is a valuable source of information andadvicefor all practising radiologists who inevitably aregoing tobe involvedin teleradiology’,

Prof.Iain McCall.

ECREXPLORESISSUES& CHALLENGESOFIMPLEMENT ING TELERADIOLOGY

costs. IT solutions offer the opportunity tocreatenew eco- nomicalpathwaysofpatient care.But it is astruggle for the ECR Europeanradiology community tomeet the challenge of changing oldstructuresand toprovidemodern diagnostic pathwaysfor the healthcare system of tomorrow.The build- ‘CHALLENGES FOR ing of medicalexpert networks via telemedicine will not solveall problems but lead toahigher availability of expert TELERADIOLOGY’ knowledge in hospitals andincreaseddiagnosticquality in patient care withreducedcosts. Inmy presentation I will introduce teleradiology aspacesetter for the continuous SESSION PREVIEW process of cross-linking in healthcare. SUNDAY, MARCH 5,8:30 -10:00AM Teleradiology ande-learning

Prof.Davide Caramelle The distribution of radiologicalimages is no longer confined Teleradiology:Pacesetter for to the hospital,sinceinmany instances regionalPACS sys- telemedicine and the health tems are emerging as the best solution for arapidly consol- infrastructureof tomorrow idating healthcare sector.This trend will make the term "tel- eradiology"obsolete,since teleradiology is progressively Prof.Matthias Matzko becoming just another PACS function. Moreover,hospitals The rapidly changing Europeanhealthcare environment faces that haveaPACSsystem haveexperienceditsability to alackoffinancialresources due toincreasing innovations in improve the quality of teaching,due to the availability of therapy anddiagnosticmethods withdramatically increasing images andclinicaldataallowing access topathological

22 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Cover Story Teleradiology ❚❚❚

examples,facilitating the construction of multimedia teach- The use of teleradiology proposedby my presentation will cen- ing files,andpreparing physicians to use the resources of e- tre on the holisticmanagement of medicalinformation rather learning. Presently thereare many radiologicalresources thansimple transmission of images from one site toanother. available on the Internet.EURORAD, the e-learning initiative of the EAR hasmadeover 1,500 peer-reviewed teaching files Teleradiology -bane or boon? available on the web.Inmy presentation I will discuss how localradiologicalarchives have turnedintoanactivereposi- Dr PaulDubbins tory of professionalknowledge updatedandenrichedat The UK Government hasintroducedaraft of policies to every encounter withany correctly diagnosedpathology. address the need toincrease imaging investigations in the faceofasevereshortage of radiologists. Government Workload andTeleradiological coordinated teleradiology has the potential torespond to Services peaks and troughs in demand, toallow rapidservice expansion and toprovideimprovedefficiency.However, Prof.Lluis DonosoBach potentialproblems related to the outsourcing of imaging Across Europe, thereisahuge increase in demandfor radiol- exist suchaspatient consent,quality assurance,commu- ogy services. However,asour workload increases in tandem nication,effect on existing workforceandcost not explic- with the rising shortage of radiologicalstaff in Europe, we itly addressed within the proposals. Although technology need toexamine eachelement of this workload in order to canensure dataprotection,it does not address patient ensure that it is managedin the most efficient way.Inmy permission to transmit images abroad. forthcoming presentation,I will discuss the elementsof work- load management, togenerateanew approach that will take Uniformity of CPD requirements,appraisalandin the UK full advantage of this situation. revalidation are unresolvedand the assessment of lan- guage skills is not subject toclose scrutiny.The initial Teleradiology is not merely aservice that produces diagnostic workdevelopedby the UK allows us toaudit the value reports. Other elementssuchasprioritising exams,audit pro- of teleradiology and todevelop amodel for optimising cedures,liaising withcolleagues todecide which type of treat- care. ment will benecessary,andreviewing imaging procedures to determine report accuracy andoverall therapeuticandclinical For further details, impact,are equally significant. please visit www.ecr.org

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 23 Feature MANAGING LARGE-SCALE RESEARCH PROJECTS ARADIOLOGIST’SPERSPECTIVE ON THEROTTERDAM STUDY

Over fifteen years ago, the Department of Imaging Brings Added Epidemiology andBiostatistics of the Erasmus MC Value University Hospital,Rotterdam,established the Using imaging,it is possible toidentify the RotterdamStudy,one of the world’s largest ongoing presenceofstructuralandfunctional changes anddisease before the onset of population-based studies.The RotterdamStudy is a clinicalsymptoms. This presentsmajor prospective,population-based study aimedat inves- prospectsfor epidemiologicalresearch. tigating chronicdiseasein the elderly.Thesedis- AUTHOR Firstly,imaging characteristics that reflect eases constituteamajor societalburden,bothin terms of disease-specificpathology -especially if A AD VANDER L UGT, monetary costs and suffering of patients and their relatives. measurable in anearly phase -providebet- R ADIOLOGIST, The findings from the RotterdamStudy will undoubtedly con- ter outcome measuresinetiologicstudies of D EPARTMENT OF R ADIOLOGY, neurodegenerativeand vasculardisease. E RASMUS MC, R OTTERDAM, tribute toimprovedprevention and treatment of chronicdis- Secondly,imaging may allow early identifica- T HE N ETHERLANDS easein the elderly.In this article,I will discuss the role of the tion of people at risk for clinicaldisease that A . VANDERLUGT@ radiology department in contributing to the success of this may benefit from preventiveinterventions. ERASMUSMC. NL long-term researchproject,andhow this is managed. Due to the ongoing RotterdamStudy and the Structureof the Rotterdam available expertise obtainedin pilot projectsinbothbrain Study imaging and vascularimaging, the researchenvironment at ErasmusMC wasoptimal toinitiatealarge-scale,prospec- Inhabitantsof the Ommoordsuburbof Rotterdamaged tive,population-basedneuro-imaging andcardiovascular 55 years or older at the time of initiation wereinvited imaging study.In 2002 the DepartmentsofEpidemiology and toparticipate. The cohort now comprises more than BiostatisticsandRadiology of ErasmusMC thereforedecided 10,000 participants, who wereexam- tocollaborateby acquiring MR inedat baseline andevery two to andMultisliceCT (MSCT)images three years thereafter.Eachpartici- withstate-of-the-art equipment pant is continuously monitoredfor Imaging allows early from the participantsin the major morbidity andmortality RotterdamStudy. through linkage of the study database identification of withrecordsfrom the generalpracti- people at risk My role in the study is asProject tioner and the municipality.Complete Leader for Radiology in both the information about exposure statusof MRI andMSCT aspectsof the participantsisavailable for the entirefifteen years study.Inorder tofulfil my obligations,my clinical workload including vascularrisk factors andmarkers of vascular hasbeen reduced, withhalf my working time spent on disease,lifestyle factors including dietary information, research. medication use,inflammatory markers andendocrine factors,as well asa variety of other laboratory assess- Toensure high participation rates in the imaging portion of ments,storedbloodsamples andDNA.Twoof the the study,adedicatedMR1.5Tscanner wasinstalledin the major themes within the RotterdamStudy are Neuro- suburbof Ommoordin connection with the existing research epidemiology andCardiovascularEpidemiology facilities. This set-upallows us tokeep stringent quality con- focussing on neurodegenerative,cerebrovascularand trolover upgrades,imaging proceduresandmaintenance cardiovasculardisease. changes andguarantees that the same scanner will be used

24 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Feature ❚❚❚ for repeatedimaging. Practicalandfinancialissues preclud- The widely-held view that neuroimaging haslittle or no impact edplacement of amultisliceCT scanner in Ommoord. on treatment of disease in the elderly,combined withalackof Therefore,participants wereinvited to visit ErasmusMC, formal training in this area, mean that many question the placeof wherea16-row MSCT scanner wasallocatedfor researchpur- poses. neuroimaging in treating patients withdementia.However, when weexamine the challenges in treating andmanaging this particu- Challenges of Collaboration lardisease,can wereally ignore the role imaging couldpotentially Any collaboration between suchalargenumber of depart- play in providing clinically essentialinformation? mentsinvolves inherent conflictsin terms of input,both financialandpersonnel-related, andoutput,suchascredits. Participating departmentsrealise that high-quality research canonly beperformed when all departmentsbring the best NEUROIMAGING IN GERIATRICS of their experience to the table. Therefore,abusiness plan wasmadein which the responsibilities,obligations and rightsof the different researchgroups wereformulated.One Currently,neuroimaging canbedivided, in broad terms,into of the specifications of this planmeans that PhDstudents structuralimaging i.e. what the brain physically looks like from the different departments,including Radiology,are andfunctionalimaging,i.e. how the brain is working. It could employeddirectly by the RotterdamStudy. beargued that application of these techniques to the clinical practiceofoldage psychiatry haslaggedbehind their use in What is the Role of the Department other medicalspecialties. This is due toanumber of reasons, of Radiology? suchaslimitedaccess,availability andcost.Inaddition, Ourdepartment contributes astate-of-the-art MRI andMSCT therehasbeen a tendency toshy away possibly because of scanner that wereinstalled under the guidanceofourphysi- limitedformal training in interpretation of brain scans,and cist andare operatedby technicians appointedand trained for radiologists toproducescanreports whichmay lackrel- by ourdepartment.Secondly,scanprotocols weredeveloped evance toclinicalpsychiatry. by CT andMRI physicistsof the Department of Radiology. The development of MRI protocol wasprecededby extensive When shouldascanbeperformed?The thresholdfor per- discussion between the involvedneuro-epidemiologist,radi- forming ascanisdifficult todetermine andno clearconsen- ologist,physicist andscientistsof the image-processing susexists. Nevertheless, thereisageneralshift towards the department. view that all patients withdementiashouldbescannedat least onceduring their illness. Ifscanning is combined with Ourcollectivegoal was toacquireimaging data that could accurateclinicalinformation,it offers the highest standardof provideextensive,high-quality information andinsight on diagnosticaccuracy currently available. Ultimately, tech- the aforementionedbiomarkers of pre-clinicaldisease niques suchasMRI andCThavean unassailable role in the processes,and toensure that imaging data wereeligible for diagnosis of dementiabecause no combination of first line automatedimage processing. All of the image acquisition clinicalandlaboratory findings (whichexcludeimaging) can had to take place within 30 minutes. Also,aprotocol was identify all causes,particularly those whichmay bereversible developed toprevent subjects withcontra-indications for or treatable. Traditionally, the use of structuralimaging in the MRI-exams toparticipatein the MR imaging study.Lastly, primary degenerativedementiashasbeen used toexclude proceduresfor the handling of incidentalfindings that may AUTHOR other conditions. Recently the emphasis hasshifted toiden- haveimportant healthconsequences for the participants, D R .B OB B ARBER tifying changes consistent with the underlying type of wereassessed. C ENTRE FOR THE H EALTH OF dementia. THE E LDERLY ,NEWCASTLE Conclusion G ENERAL H OSPITAL, Functionalimaging now offers essentialcomplementary infor- Inclosure,it is my experience that large-scale researchstud- N EWCASTLE UPON T YNE,UK mation in exploring age-relateddiseases. In the future,com- ies bring their ownspecialchallenges anddemandsfor R OBERT .B ARBER@ NCL. AC. UK binedstructuralandfunctionalimaging may well beshown involvedimaging professionals. Inmy opinion, the best and toimprovediagnosticdiscrimination andprovidefurther only approachis toenter intosuchaproject withaspirit of insightsinto the biologicalbasis of dementias, the nature of teamworkandcollaboration,in order toensure the best pos- their symptoms and the relativecontribution of different sible blendof expertise andexperience,andof course the pathologicalprocesses that underpin cognitiveimpairment. most enlightening outcome. It remains tobeseen where the Increasingly,asfurther therapeuticoptions become available resultsof this study canpotentially lead healthcare in the andimaging techniques become moreable toprovide useful future,but no doubt it will haveconsequences morefar- diagnosticandprognosticinformation,structuralandfunc- reaching thaneven present collaborators haveenvisioned. tionalneuroimaging will become animportant part of the clinical work-upinpsychiatry.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 25 ❚❚❚Feature

DIGITAL VS.COMPUTED RADIOGRAPHY

The ongoing contest between digital radiography andcomputed radiog- ISSUESINV OLVEDINCHOOSING raphy for first placein the digitalimaging market continues to throw up WHICH SYSTEM TO IMPLEMENT new issues.Although bothCR andDRimprove workflow andproductivi- ty when compared to their non-digitalpredecessor,bothhave their own specificadvantages anddisadvantages and the main factor in choosing one system over another seems tocome down tocost.Here wepresent a snapshot of some of the key pros andcons when choosing which system toimplement,affecting areas suchas productivity, cost-effectiveness,image quality and technologist productivity.Are the initialcost-savings of choos- ing CR over DR sensible when looking at along-termproductivity model? Is it even feasible for med- icalfacilities, who suffer increasingly tight budgets andlower levels of publicfinancing,as well as staff shortages andanexponentialincreasein the number of imaging procedures carriedout, tocon- sider investing in DR?Here we take abrief look at the main issues.

COMPUTED RADIOGRAPHY (CR) DIGITAL RADIOGRAPHY (DR) R e f e r s t o a s y s t e m b y w h i c h s t o r a g e p h o s p h o r c a s s e t t e - b a s e d R e f e r s t o t e c h n o l o g i e s u s i n g a n e l e c t r o n i c , n o n - c a s s e t t e d e t e c t o r , f o r e x a m p l e s y s t e m s r e p l a c e t h e t r a d i t i o n a l f i l m - s c r e e n c a s s e t t e . a m o r p h o u s s e l e n i u m , a m o r p h o u s s i l i c o n a n d c h a r g e - c o u p l e d d e v i c e s ( C C D s ) . -CR hassignificantly lower start-upcosts thanDR, because of the potential -Current researchconfirms that DR is significantly faster andmoreefficient thanCR.AtypicalCR exam for radiography rooms toadapt their existing system moreeasily,by replac- can take up to three times the average time taken by aDRexam. Serviceproviders suchasCanon ing the traditionalfilm cassette withaCRcassette. haveledscientificstudies that prove that aDRchest-examination in twodirections, using DICOM -Although DR is generally accepted tobe the speedier technology,in fact reduc- modality WorkList canbedone in 100 seconds,compared to 300 seconds withfilm screen technolo- ing the number of steps in the CR workflow process couldreapsimilarbene- gy.This saving in terms of time is directly related toreduction in the number of post-processing fits. Cassettehandling is still aproductivity issueinCR but thereare emerging workflow steps,rather than time taken in acquiring the image. While aDRpreview appears within technologies that may challenge DR in this aspect. moments,aCRimage canbejudgedin 90 seconds. -Despiteinitialcost savings in choosing aCRsystem over DR particularly -DR not only incurs aprohibitively higher start-upcost thanCR, it also requires some level of costly when considering start-upcost,higher overheadsin terms of investment in maintenance,and users must take intoaccount factors suchas the eventualreplacement cost for DR maintenanceandstaff productivity must be taken intoaccount.Because a detectors. However,detectors canlast on average more thansix years, withanestimatedeconomic CR system necessitates workflow steps suchas taking the cassette to the life cycle of around twelve years,so the associatedrisk of detector failure is relatively low.Also, reader,medicalfacilities withahigher throughput may find that long-term,a many serviceproviders offer tocover this risk withaninsuranceofapercentage per order per year DR system leads tohigher cost-effectiveness that is well acceptedin the market place. -DR is considered tobespeedier in producing areadable image,asimages are sent straight to the PACS system. Not only this,but DR systems producebetter quality diagnosticimages. Conclusion -AsDR emerges, thereisanearly emphasis being placedon this technology asacompletesystem, Although many agree that DR is the ‘wave asit has the potentialfor room add-ons. Direct DICOM output associated withDR goes some way in of the future’,it canbeprohibitively addressing productivity issues. expensive. However, thereisreluctancein -Hospitals are slower tochoose DR systems,partly because of priceandpartly because the equip- imaging departments toinvest in CR, ment's sizeandrelativeimmobility limitsits use. Inpractice,hospitals tend to use amix of devices knowing that in the future they may have so DICOM-standardsoftware must beable tohandle images from multiple sources. toconvert toDR.One argument sees DR asbecoming the standardof the future,as it eliminates the needfor film storage space,speeding delivery of images. Whether usedon itsown SaysVanHedent;‘Technology is changing at arapidrate. We or aspart of amix of technologies,many healthcare facilities AUTHOR need to take intoaccount that this will also affect the growth are deciding that initialhigh outlay in choosing DR over CR of CR, whichIbelieve will become obsoletein the future, D ERVLA S AINS is worthit.DrEddy VanHedent,Head of Radiology at the only maintainedfor bedsideRx in intensivecare units where M ANAGING E DITOR, ASZ Community HospitalinAalst,Belgium,hasrecently com- patientscannot bemoved toimaging departmentsorcen- IMAGING M ANAGEMENT pletely digitised the department,except for mammography. tres. However,in the long run,bedsideDR will also no doubt EDITORIAL@ His move toCR wasmainly inspiredby the need tooptimise become apossibility.OnceDR becomes less expensive,I too IMAGINGMANAGEMENT. ORG workflow of medicalstaff,and tocope with the approximate- will consider taking the next step in implementing this tech- ly 250 patientsper day who are examinedin the department. nology.’

26 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES

❚❚❚Feature

The need for clearer, sharper image quality is paramount in order toaid in the improved detection of diseases.Thereis no doubt that the contrast media segment is growing,as part of the overall risein the consumption of imaging services across Europe,and the increasing drive by medicalfacilities toimproveand expand imaging equipment installations,helping promote the growthof the overall market.BothCT and MRIcomprise the main segments wherecontrast mediais utilised. Frost &Sullivanestimate that sales in the overall Europeancontrast media market will reach up to$915 million by 2008. COST-EFFECTIVENESS IN RADIOPHARMACEUTICAL R&D

ACost–Efficient Team STREAMLINI NG Most small- andmedium-sizedcompanies meet the cost con- MANA GEMENT PRACTICE IN tainment challenge by hiring astaff that is small enough to becost-effective,but largeenough toat least cover the need SMALL-TO MID-SIZED for people with the requiredexpertise for the specificproject COMPANIES they are running. This usually means that the company has asmall management teamconsisting of aGeneralManager, FinancialOfficer,ScientificDirector andaTechnical

AUTHOR It is common knowledge that the development of anew Development Officer.The management teamissupportedby pharmaceuticalisprohibitively expensive. Blue-chip pharma alimitedstaff of expertsincluding aManufacturing Officer, L ARS V EDIN M.D. companies havequotedfiguresin the range of hundredsof Regulatory Officer,PreclinicalExpert,andexpertsinClinical G ENERAL M ANAGER millions of US dollars,costs that are rising yearby year. In Development andPatent Management.Though some by CMC C ONTRAST AB, today’s market,even larger,moreestablishedcompanies necessity servemultiple responsibilities, the payroll caneas- S TOCKHOLM,SWEDEN hesitate toengage themselves in new pharmaceuticaldevel- ily have tocover a teamofover fifteen to twenty individuals LV@ CMC- CONTRAST. SE opment projects unless the product is considered tobelow who, withextensiveeducation,experienceandprofessional risk. Asaresult of this, the number of approved‘New background, demandfairly high salaries. However experi- ChemicalEntities’hasdecreasedin recent years. This cost encedstaff may be,acertain number of their tasks will explosion is driven by the increasedrequirementsfromreg- involve work where they havelimitedexperience,sinceit is ulatory authorities,and ultimately,of course,serves the impossible tohirestaff withevery requiredcompetence,and patients’ needfor safe andefficaciouspharmaceuticals,and different types of bottlenecks usually occur. Tomeet the chal- society’s needfor cost-effectivedrugs. When even big com- lenges of cost containment,ourcompany haschosen amore panies havedifficulties in financing new projects,it is easy advancedstrategy. to understand that small- andmedium-sizedcompanies are facing aneven moreonerous task toget aradiopharmaceu- OptimalOrganisationalStructure ticalproject off the ground.AsCEO of suchanenterprise, we Ourorganisationalstructure enables us toengage the best havehad toengage new strategies in order tooffset and possible competencefor eachspecific task. All proceduresin reduce the considerable costsfor this R&D process. the development process are done at the highest possible quality level according toexisting regulations. The manage- ment of the development project must strive tobeeffective, competent and withquick throughput.The permanent staff of ourenterprise numbers only three persons,aManaging Director,aScientificDirector andapart-time Financial Director.Thesepeople all haveextensiveexperienceinrun- ning pharmaceuticaldevelopment projects withspecialfocus on contrast media.Twomembers of staff are qualifiedmed- icaldoctors,one who is bothM.D.andPharmacist.This means that ourpermanent staff is highly competent in the areaof radiologicalpharmaceuticals. Wehaveinitiateda project management structure for our teamas wehavefound it morecost-effective than the traditionalline officer

28 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Feature ❚❚❚ approach,andall the specialfunctions for whichour team are not responsible,are outsourced tosubcontractors with expertise in those areas. The completepharmaceutical development,including analyticaldevelopment,manufac- TECHNOLOGY FORECAST – turing,packaging development,documentation andfiling is done in co-operation withaGMP-certifiedpharmaceuti- IMAGING SERVICES calcontract manufacturer.

Onone hand, of course,outsourcing highly specialised services canalso bequitecostly,in fact substantially more Medicalimaging playsasig- costly thanaregularemployee with the same competence. nificant role in the diagnosis On the other hand, asubcontractor will only bill for actu- andmanagement of dis- al time spent engagedin the requiredservice. Inpharma- ease. Technologicaldevel- ceuticalresearchanddevelopment projects, the needfor opmentshavesignificant different competencies varies alot over time,andin my implications on how imaging equipment is used.Knowledge experience, this extensive use of subcontracting has of the ongoing developmentsbeing madeinmedicalimaging turnedout tobeextremely cost effectivein the long-term. technology is essentialfor healthcare planning.

Development of Contrast Media: ComputedTomography SpecificRequirements What are the technicallimitations witha16-slicescanner com- Contrast mediaare legally classifiedaspharmaceuticals. In pared toone with 64-slices? The answer dependson what the ourcase, weare developing amanganese-based, orally application is. For non-cardiac applications,16 slices is usual- administeredcontrast mediumfor enhancement of the ly sufficient.Cardiac imaging hasgainedalot of attention liver andbile ductsinMRI.However, the development of because it is the most technically challenging anatomy to radiologicalcontrast agentsisless complicatedcompared CONTACT ECRI E UROPE image. Limitations suchashigh x-ray dose andhigh toother pharmaceuticaldevelopment.This is mainly due heartrates remain,so the push is for morespeed.The latest to the fact that contrast mediaare administered to W ELTECH C ENTRE R IDGEWAY , W ELWYN G ARDEN C ITY , commercially available development is the addition of asec- patientsinsome cases over afew individualsessions. U NITED K INGDOM ond x-ray tube. The second tubecouldhavesignificant ben- Therefore,no extendedperiodsofmonitoredfollow-upare INFO@ ECRI. ORG . UK efits,in terms of speed, dose andmoreclinical utility.Another needed, reducing the needfor complicated toxicological development, though not yet commercially available,is the investigations. In this way,costsassociated withbringing WWW. ECRI. ORG . UK increase in slices to 256.While the issueofradiation dose is acontrast mediaproduct tomarket are lower thanfor agrowing concern,it seems inevitable that the use of CT will other pharmaceuticals. increase.

One important aspect of pharmaceuticalresearchand MagneticResonanceImaging development,is the gathering andsystematicfiling of total MR imaging has twoadvantages over CT;soft tissuecontrast competenceandspecialisedknowledge. Outsourcing and andabsenceofionising radiation. However,it is associated subcontracting present uniqueproblems. Ascompetence withlong exam times,significant patient discomfort andcon- andknowledge are spread among different persons and siderable complexity.Three developmentsinMR imaging are groups,and varioussubcontracting companies, wemust evident today:higher fieldstrength,moreopen magnets,and avoiddilution of expertise,andmaintain very well-man- simplifiedimage acquisition. Higher fieldsstrengths enable aged, interactivebusiness relationships tokeep upconti- faster andhigher resolution imaging. This is particularly nuity witheachsubcontractor,andensure that compe- important in exams that attempt todetect small and transient tenceremains in asfew handsaspossible. Inourcase, we changes. High fieldstrength(3T)systems are becoming wide- havemadeone person who is a very experienced toxicol- ly useddespiteadditionalcosts. However,for routine patient ogist,responsible for following the whole project through. exams thereislittle data toshow concomitant benefits. As moreclinicalexperienceisgained 3Twill continue togrow. This person serves ashead of preclinicaldevelopment and Patient comfort was the main reason for the popularity of toxicology on asubcontracting basis. In this way, wecan open MR systems. InEurope,open MR never found wide- savecosts through efficient staff management andorgan- spread use. Today,1.5TMRsystems are becoming increasing- isation without losing knowledge or expertise. ly “open”, withshorter and wider bores coupled withacoustic noise reduction. MR is the most complex imaging tool in rou- tine use. Manufacturers now provideanumber of software packages that help the users acquireMR images *

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 29 ❚❚❚Feature

CONTINUED * morereliably.These packages canbeexpensive, ogy tojustify additionalexpense. Fluoroscopy equipment is T ECHNOLOGY F ORECAST – so users need tocarefully determine which tools they need. now being usedmorefor interventionalproceduresasCT I MAGING S ERVICES becomes the predominant tool. Flat panel technology togeth- Ultrasound er withfast computing power is allowing CT-like images to Asdigitalsignalprocessing becomes smaller andcheaper, beproduced withfluoroscopicequipment.While images do the amount you cando with ultrasoundis increasing. not match those from CT they allow muchimprovedguidance Portable oncemeant the devicecouldbe wheeledaround, for interventionalprocedures. now you canfit it in yourpocket.With the development of small imaging devices healthcare facilities are being forced to Nuclear Medicine (SPECT andPET) reconsider how ultrasoundis used.However,large,full fea- While gammacamera technology usedin nuclearmedicine ture ultrasound unitsremain important diagnostic tools. In hasnot really changed, the increasing interest in hybridscan- particular, 3Dimaging hasproved tobemore thanagimmick ners has. The combination of PETandCTwasone of the fac- asit helps reduce variation between users. tors that dramatically affectedgrowthofPET.Now,higher specification CT scanners are being combined withSPECT. Mammography While the clinicalbenefitsare not clearcompared toPET, it In 2005 the resultsof the long awaitedACRIN digitalmam- is likely that SPECT CT will become increasingly common. A mography study werereleased, showing that for women lot dependson the development of radiotracers. The same is under the age of fifty, withradiographically denser breasts, truefor PET, the main issuebeing that new tracers being digitalmammography improvedcancer detection. So,despite developedhave very short half-lives,limiting availability and higher costs, thereisnow increasedpatient demand.Anum- increasing costs. Perhaps the most significant development ber of alternative technologies are either available or under in PETimaging is not technology but the muchstronger evi- development for breast cancer detection. None of them are dencebeing sought todemonstrateitseffectiveness. promising toreplacemammography as the primary screening tool. Instead, they are being developed toscreen high-risk Computer AidedDetection groups or reduce the number of breast biopsies. Breast MR Historically computer aideddetection hasfocusedon the imaging is probably the most widely used technology. needsofmammography.Mammography CAD is generally However, until alternative technologies demonstratesensitiv- acceptedasimproving detection,particularly when only one ities andspecificities approaching that of minimally invasive radiologist viewsimages. Asmore users move todigital biopsies,it is hard tojustify their widespread adoption. mammography it is likely that CAD will become astandard tool. Interest is moving toother areas that wouldbenefit Radiography from CAD.Early resultsofCAD are promising. Ifsuchscreen- Now that digitalimage storage andreview is indispensable, ing is tobecome common then it is very likely that CAD will it is necessary for non-digital technologies tobecome inte- beanessentialpart for the viability of suchexams. Inaddi- grated.Hencegrowing demandfor digitalradiography.The tion topure CAD, i.e.,detection,automatedcomputer analy- technology usedin flat panel detectors (DR)appears tobe sis of images is becoming increasingly important.Muchof mature now, withnorecent technologicaldevelopmentsas this is driven by the vast increase in the number of CT images faras the detector is concerned.Incontrast, the technology being generated.The resulting 3Ddatasetscannot reason- usedin reusable phosphor plates (CR)iscontinuing todevel- ably bereviewedby humanobservers. But computers can op.Image quality is improving andimage-processing times rapidly measure andanalyse datasets,often withhuman are reducing. The result is that what wasonceacleardistinc- interaction, toproducequantitativeresults. Problems include tion between DR andCRis not so clear-cut today.One inter- how tofit CAD into the workflow so that disparatesystems esting development for bothCR andDRis the integration of andhumans can workeffectively together. both technologies intoaportable x-ray unit that canbe used around the hospital. Most technologicalchanges are the result of faster computer processors. Faster image acquisition,regardless of modality, Fluoroscopy means that diagnosticinformation is less dependent on The ubiquitousimage intensifier is gradually being replaced patient’s conformance. 3Ddatasetsare becoming increasing- by the smaller andmoreexpensiveflat panels (similar to ly common. The most likely result of this is that morerefer- DR). Asignificant amount of diagnostic workbeing done in ring physicians andpatients will demandmoreadvanced radiology departments withfluoroscopy moved toCT.More imaging. Tempering this will be the growing demandfrom recently flat panels are becoming morecommon on angio- payers (i.e.,governments) for evidencebasedresearch. graphicequipment andnow are beginning toappearongen- These changes will requirenew equipment,different skill eral-purpose radiographic/fluorography equipment.The inter- sets,and very different models for workflow within radiology esting aspect is what manufacturers cando with the technol- departments.

30 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES COMPUTED TOMOGRAPHY SCANNING SYSTEMS

HEALTHCAREPRODUCT COMPARISON CHART

ECRI is a totally independent non profit research agency designatedas aCollaborating Centreof the WorldHealthOrganization (WHO). Suchorganizations CONTACT areappointed tocontribute toWHO’s publichealthmission ECRI E UROPE by providing specializedknowledge,expertise,and support W ELTECH C ENTRE R IDGEWAY , W ELWYN G ARDEN C ITY , in the healthfield to the WHOandits member nations.ECRI H ERTS AL7 2AA, U NITED is widely recognizedas one of the world’s leading independ- K INGDOM ent organizations committed toadvancing the quality of INFO@ ECRI. ORG . UK healthcare withover 240 employees globally. WWW. ECRI. ORG . UK

ECRI’s focusismedicaldevice technology,healthcare risk and quality management,andhealth technology assessment.It provides information services and technicalassistance to more than5,000 hospitals,healthcare organizations,min- designedfor use in medicalimaging from itsHealthcare istries of health,government andplanning agencies, volun- Product Comparison Chart System (HPCS), whichcontains tary sector organizations andaccrediting agencies worldwide. over 280 reports. The HPCS reportscontain extensiveinfor- Itsdatabases (over 30),publications,information services mation about the technology,itspurpose,itsprinciples of and technicalassistanceservices set the standardfor the operation,stage of development andreportedproblems. healthcare community. This extract from ourdatabase contains model by model Amongst itsmany productsandservices ECRI is pleased to specifications for easy assessment andreview.The Computed providereaders of IMAGING Management withsample infor- Tomography Scanning Systems comparison chart includes mation on ComputedTomography Scanning Systems ECRI’s ‘Recommendedspecifications’(generic templates) whichcanbe usedfor comparison FOOTNOTESTOTHE PRODUCT COMPARISON CHARTONPAGES 32 - 34 and tendering purposes.

E C R I E1 These recommendations are the opinions of All of ECRI’s productsandservices ECRI's technology experts. ECRI assumes no liability for are available through the European decisions madebasedon this data. Office,addressing the special requirementsofEurope and the UK. G E H e a l t h c a r e G1 1.375:1,1.75:1(16) G2 50/60 Hz, 3-phase deltaor Wye Utilising some of the world’s largest healthrelateddatabases,help,sup- P H I L I P S P1 (32,256 effective withDFS) port andguidancecanbegiven to P2 optional 768 x 768,1024 x 1024 ourEuropeanclientsat alocallevel. P3 with 3-Dcone beam P4 3-phase Publication of all submitteddatais S I E M E N S S1 dissipation not possible:for further information S2 withDualPentiumXenon please contact ECRI or editorial@ imagingmanagement.org. T O S H I B A T1 0.5,1,2,3,4,5,8(all x4) T2 (IEC standard) T3 50-500 mAin 10 mAsteps

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 31 ECRI E1 PHILIPS MEDICAL PHILIPS MEDICAL GE HEALTHCARE

M O D E L H i g h C a r d i a c B r i l l i a n c e 1 6 P o w e r B r i l l i a n c e 1 6 - s l i c e L i g h t S p e e d 1 6 ( G e m i n i 1 6 P o w e r ) WHEREMARKETED Worldwide Worldwide Worldwide FDACLEARANCE Yes Yes Yes CE MARK(MDD) Yes Yes Yes TYPE Multislice Multislice Multislicedeletehelical Multislice Nr slices acquired simultaneously 64 16 16 16 GANTRY Geometry Rotate-rotate, slip ring Rotate-rotate Rotate-rotate Rotate-rotate, slip ring

Detectors, type Ceramic, solid-state 24mm z-axis coverage 24mm z-axis coverage HiLight ceramic solid-stateGOS solid-stateGOS -Number of rows 64 Not specified Not specified 24 -Elements per row Approx1,000 672 672 912 Number of detection channels 64 x 1,000 16,128elements P1 16,128elements P1 16 x 912 Scan times, sec 360° 0.4-2 0.5,0.75,1,1.5, 2; optional 0.4 0.5,0.75,1,1.5, 2; optional 0.4 0.5,0.6,0.7,0.8,0.9,1,2,3,4 -Partial 0.25 0.33; opt 0.28 0.33, 0.49; opt 0.28 NA Slice thickness,mm 0.4 0.6-12 variable 0.6-12 variable 0.63,1.25,2.5,3.75,5,7.5,10 X-ray fanbeamangle,° 54.4 54.4 55 Gantry tilt,° ±30 ±30 ±30 ±30 Gantry dimensions,H x W x D, cm 203 x 239 x 94 205 x 229 x 98 188.2 x 222.3 x 100.6 Gantry weight,kg < 2,000 1,764 2,100 1,269 Gantry aperture,cm 70 70 70 70 Scanlocalizer Laser Laser Laser Laser X-RAYTUBE X-ray tubeanode -Heat storage,HU 7,0,000 8,0,000 (MRC technology) 8,0,000 (MRC technology) 6,300,000 -Heat dissipation rate,HU/min 700,000 1,610,000 1,610,000 840,000 Tubecooling Oil or water Oil/air Oil/air Oil/air Tubefocal spot,mm 0.5 x 0.7 0.5 x 1 small,1 x 1large 0.5 x 1 small,1 x 1large 0.7 x 0.6, 0.9 x 0.7 Optional tubes NA Conventional5.2 MHU Conventional5.2 MHU NA X-RAYGENERATOR kWoutput 60 60 60 53.2 kVp range 80-140 90,120,140 90,120,140 80,100,120,140 mA range 20-500 20-500 in 1mAincrements 20-500 in 1mAincrements 10-440 HELICAL SCANNING Yes Yes Yes Max scan time, sec 100 100 100 120 Max scan volume,cm 150 162 162 170 Spatial resolution,lp/cm 20 24 24 Same as axial Pitch NA 0.13 to1.7, user selectable 0.13 to1.7, user selectable 0.5625:1, 0.9375:1, G1 Reconstruction time per image, sec 0.2 0.025, 3-Dcone beam 0.17, 3-Dcone beam; optional 0.05 0.17 PATIENTTABLE Range of movement -Vertical,cm 40-100 52-104 52-100 51-107 -Longitudinal,cm 150 190 190 170 Scannable range,cm 150 162 162 170 Max load capacity,(accuracy),kg 200 (not specified) 204(±0.25mm) 204(±0.25mm) 180 (±0.25mm), 205(±1 mm) IMAGEPROCESSING Computer CPU Intel,Windows OS Intel,Windows OS Open architecture/ LINUX ScanFOVs,cm 50 Up to50 Up to50 25,50 Reconstruction matrixes 512 x 512 256 x 256,512 x 512;P2 256 x 256,512 x 512; P2 512 x 512 Reconstruction time -Per slice, sec 0.2 Up to40 images/sec P3 Up to 6 images/sec P3 6 frames/sec -For localization scan, sec Real time 5 5 Real time DISPLAY Monitor size 20" 18" flat LCD; also 21" CRT 18" flat LCD; also 21" CRT 20"(2),opt flat Matrixes,pixels 1024 x 1024 1280 x 1024 1280 x 1024 1280 x 1024 Range of CT numbers -1,000 to+3,000 -1,000 to+3,095 -1,000 to+3,095 -1,024 to+3,071 Image enlargement 10x Up to10x; real time Up to10x; real time Up to8x Max no. slices displayedat once 16 Not specified Not specified 16 IMAGESTORAGE Harddisk,GB 100 292 292 146 No. online images 75,000 514,242 uncompressed(512 x 512) 514,242 uncompressed(512 x 512) 250,000 Archival storage MOD, CD,DVD 9.1 GB rewritable EOD, 620 MB CD 9.1 GB rewritable EOD, 620 MB CD 2.3 GB MOD, DICOM 3.0 PERFORMANCE Minimuminterscan time, sec 0 None None 1 Dynamic scan rate Not specified Not specified 960 scans/min High-contrast spatial resolution - 0%MTF, lp/cm 20 24 24 15.4 -50%MTF, lp/cm 10 Not specified Not specified 8.5 Low-contrast res, -mmat %at < =4 rads 4at 0.3%at 2 rads 4at 0.3% 4at 0.3% 5at 0.3%at 1.8 mGy 8" CATPHAN Noise,%at < =2.5 rads 0.3 at 3 rads 0.27 0.27 0.32 at 2.85 rads CORONARYARTERY Yes Yes Yes Optional CALCIFICATION SCORING DICOM 3.0 INTERFACE Yes Yes Yes Yes RECOMMENDEDROOM SIZE,m 2 25 25.9 25.9 28minimum POWERREQUIREMENTS 3-phase 200-500 VAC, 50/60 Hz,100 kVA P4 200-500 VAC, 50/60 Hz,100 kVA P4 460/480 VACnominal, G2

32 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES GE HEALTHCARE GE HEALTHCARE

L i g h t S p e e d P R O 1 6 L i g h t S p e e d P R O 3 2 S O M A T O M S e n s a t i o n 6 4 S O M A T O M S e n s a t i o n C a r d i a c M O D E L C a r d i a c Worldwide Worldwide Worldwide Worldwide WHEREMARKETED Yes Yes Yes Yes FDACLEARANCE Yes Yes Yes Yes CE MARK(MDD) Multislice Multislice Multislice spiral Multislice spiral TYPE 16 32 64 16 Nr slices acquired simultaneously GANTRY Rotate-rotate, slip ring Rotate-rotate, slip ring Continuous rotate,low-voltage Continuous rotate,low-voltage Geometry slip ring slip ring HiLight ceramic HiLight ceramic UltraFast Ceramic withadaptive UltraFast Ceramic withadaptive Detectors, type array detector array detector 24 64 64 16 -Number of rows 912 912 672 672 -Elements per row 16 x 912 32 x 912 64 x 1,344 64 x 1,344 Number of detection channels 0.4,0.5,0.6,0.7,0.8,0.9,1,2,3,4 0.4,0.5,0.6,0.7,0.8,0.9,1,2,3,4 0.33,0.37,0.42,0.5,0.75,1,1.5 0.37,0.42,0.5,0.75,1,1.5 Scan times, sec 360° NA NA 0.25,0.28, 0.33; also 0.5,0.67,and1 0.25,0.28, 0.33; also 0.5,0.67,and1 -Partial 0.63,1.25,2.5,3.75,5,7.5,10 0.63,1.25,2.5,3.75,5,7.5,10 0.6,0.75,1,1.5,2,3,4,5,6,9,10 0.6,0.75,1,1.5,2,3,4,5,6,9,10 Slice thickness,mm 55 56 54.4 54.4 X-ray fanbeamangle,° ±30 ±30 ±30 ±30 Gantry tilt,° 188.2 x 222.5 x 100.6 188.2 x 222.5 x 100.6 199 x 89 x 222 199 x 89 x 222 Gantry dimensions,H x W x D, cm 1,269 1,269 2,100 2,100 Gantry weight,kg 70 70 70 70 Gantry aperture,cm Laser Laser Laser Laser Scanlocalizer X-RAYTUBE X-ray tubeanode 8,0,000 8,0,000 0.6 MHU with5MHU/min heat S1 0.6 MHU with5MHU/ min heat S1 -Heat storage,HU 1,782,000 1,782,000 5,0,000 5,0,000 -Heat dissipation rate,HU/min Oil/air Oil/air Chilled water Chilled water Tubecooling 0.7 x 0.6, 0.9 x 0.9 0.7 x 0.6, 0.9 x 0.9 0.6 x 0.7, 0.8 x 0.8, 0.8 x 1.2 0.6 x 0.7, 0.8 x 0.8, 0.8 x 1.2 Tubefocal spot,mm NA NA No No Optional tubes X-RAYGENERATOR 100 100 80 60 kWoutput 80,100,120,140 80,100,120,140 80,100,120,140 80,100,120,140 kVp range 10-835 10-835 28-670 28-500 mA range Yes Yes Yes Yes HELICAL SCANNING 120 120 100 100 Max scan time, sec 170 170 157 157 Max scan volume,cm Same as axial Same as axial 30 30 Spatial resolution,lp/cm 0.5625:1, 0.9375:1, G1 0.5625:1, 0.9375:1, G1 28.2-128freely selectable 8-32 freely selectable Pitch 0.17 0.063 0.06 0.1 Reconstruction time per image, sec PATIENTTABLE Range of movement 51-107 51-107 48-102 48-102 -Vertical,cm 170 170 200 200 -Longitudinal,cm 170 170 157 157 Scannable range,cm 180 (±0.25mm), 205(±1 mm) 180 (±0.25mm), 205(±1 mm) 200 (not specified) 200 (not specified) Max load capacity,(accuracy),kg IMAGEPROCESSING Open architecture/ LINUX Open architecture/ LINUX Multiple Intel-based servers S2 Multiple Intel-based servers S2 Computer CPU 25,50 25,50 50; optional 70 50; optional 70 ScanFOVs,cm 512 x 512 512 x 512 512 x 512 512 x 512 Reconstruction matrixes Reconstruction time 6 frames/sec Up to16 frames/sec 0.06 0.1 -Per slice, sec Real time Real time Real time Real time -For localization scan, sec DISPLAY 20"(2),opt flat 20"(2),opt flat 18" LCD 18" LCD Monitor size 1280 x 1024 1280 x 1024 1024 x 1024 1024 x 1024 Matrixes,pixels -1,024 to+3,071 -1,024 to+3,071 -1,024 to+3,071 -1,024 to+3,071 Range of CT numbers Up to8x Up to8x Yes Yes Image enlargement 16 16 64 64 Max no. slices displayedat once IMAGESTORAGE 146 146 446 376 Harddisk,GB 250,000 250,000 260,000 260,000 No. online images 2.3 GB MOD, DICOM 3.0 2.3 GB MOD, DICOM 3.0 CD-R, MOD CD-R, MOD Archival storage PERFORMANCE 1 1 0.25 0.25 Minimuminterscan time, sec 960 scans/min 960 scans/min Not specified Not specified Dynamic scan rate Not specified Not specified High-contrast spatial resolution 30 30 - 0%MTF, lp/cm 15.4,19.6-Z 15.4,19.6-Z 15 15 -50%MTF, lp/cm 10.2,19.6-Z 10.2,19.6-Z 5at 0.3%at 2 rads Low-contrast res, 5at 0.3%at 1.3 mGy 8" CATPHAN 5at 0.3%at 1.3 mGy 8" CATPHAN 0.29 5at 0.3%at 1.7 rads -mmat %at < =4 rads 0.32 at 2.85 rads 0.32 at 2.85 rads Yes 0.29 Noise,%at < =2.5 rads Optional Optional Yes CORONARYARTERY Yes CALCIFICATION SCORING Yes Yes Yes DICOM 3.0 INTERFACE 24 RECOMMENDEDROOM 28minimum 28minimum 380-480 VAC, 3-phase, 63-111 kVA 24 SIZE,m 2 460/480 VACnominal, G2 460/480 VACnominal, G2 380-480 VAC, 3-phase, 66-83 kVA POWERREQUIREMENTS

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 33 TOSHIBA TOSHIBA TOSHIBA

M O D E L S O M A T O M S e n s a t i o n O p e n A q u i l i o n 1 6 A q u i l i o n 1 6 C F X A q u i l i o n 3 2

WHEREMARKETED Worldwide Worldwide Worldwide Worldwide FDACLEARANCE Yes Yes Yes Yes CE MARK(MDD) Yes Yes Yes Yes TYPE Multislice spiral Multislicehelicall Multislicehelicall Multislicehelicall Nr slices acquired simultaneously 16 16 16 32 GANTRY Geometry Continuous rotate,low-voltage Rotate-rotate, slip ring,multislice Rotate-rotate, slip ring,multislice Rotate-rotate, slip ring,multislice slip ring Detectors, type UltraFast Ceramic withadaptive Solid-state Solid-state Solid-state array detector -Number of rows 16 16 16 32 -Elements per row 672 40 x 896 40 x 896 64 x 896 Number of detection channels 64 x 1,344 16 x 896 16 x 896 32 x 896 Scan times, sec 360° 1; optional 0.5 0.5,0.75,1,1.5,2, 3; optional 0.4 0.4,0.5,0.75,1,2, 3 0.5,0.75,1,1.5,2, 3; optional 0.4 -Partial 0.67; optional 0.33 0.32; optional 0.25 0.25, 0.32 0.32; optional 0.25 Slice thickness,mm 1.5,2,3,4,5,6,7,8,10 0.5,1, 2 (all x 16); T1 0.5,1, 2 (all x 16); T1 0.5,1(all x 32); 2 x 16; T1 X-ray fanbeamangle,° 54.4 49.2 49.2 49.2 Gantry tilt,° ±30 ±30 ±30 ±30 Gantry dimensions,H x W x D, cm 199 x 89 x 222 195 x 233 x 96 195 x 233 x 96 195 x 233 x 96 Gantry weight,kg 2,100 1,750 1,750 1,750 Gantry aperture,cm 82 72 72 72 Scanlocalizer Laser Laser Laser Laser X-RAYTUBE X-ray tubeanode -Heat storage,HU 0.6 MHU with5MHU/ min heat S1 7,500,000 7,500,000 7,500,000 -Heat dissipation rate,HU/min 5,0,000 1,386,000 max 1,386,000 max 1,386,000 max Tubecooling Chilled water Oil/air Oil/air Oil/air Tubefocal spot,mm 0.6 x 0.7, 0.8 x 0.8, 0.8 x 1.2 1.6 x 1.4, 0.9 x 0.8 T2 1.6 x 1.4, 0.9 x 0.8 T2 1.6 x 1.4, 0.9 x 0.8 T2 Optional tubes No Not specified Not specified Not specified X-RAYGENERATOR kWoutput 50 60 60 60 kVp range 80,100,120,140 80,100,120,135 80,100,120,135 80,100,120,135 mA range 28-420 10-500; 10-50 in 5mA steps T3 10-500; 10-50 in 5mA steps T3 10-500; 10-50 in 5mA steps T3 HELICAL SCANNING Yes Yes Yes Yes Max scan time, sec 100 100 100 100 Max scan volume,cm 157 175 175 175 Spatial resolution,lp/cm 16.3 18 at 0%MTF 18 at 0%MTF 18 at 0%MTF Pitch 7.2-32 freely selectable 0.8-96 mm/sec, couchtop speed 0.8-120 mm/seccouchtop speed 0.8-96 mm/seccouchtop speed Reconstruction time per image, sec 0.06 0.17 0.17 0.1 PATIENTTABLE Range of movement -Vertical,cm 48-102 31-94.4 31-94.4 31-94.4 -Longitudinal,cm 200 219 219 219 Scannable range,cm 157 180 180 180 Max load capacity,(accuracy),kg 200 (not specified) 205(±0.25mm) 205(±0.25mm) 205(±0.25mm) IMAGEPROCESSING Computer CPU Multiple Intel-based servers S2 32-bit processor x 2 32-bit processor x 2 32-bit processor x 2 ScanFOVs,cm 50,82 18,24,32,40,50 18,24,32,40,50 18,24,32,40,50 Reconstruction matrixes 512 x 512 512 x 512 512 x 512 512 x 512 Reconstruction time -Per slice, sec 0.06 0.17 0.17 0.17 -For localization scan, sec Real time Real time Real time Real time DISPLAY Monitor size 18" LCD 18" LCDcolor x 2 18" LCDcolor x 2 18" LCDcolor x 2 Matrixes,pixels 1024 x 1024 1280 x 1024 1280 x 1024 1280 x 1024 Range of CT numbers -1,024 to+3,071 -1,536 to+8,191 -1,536 to+8,191 -1,536 to+8,191 Image enlargement Yes Up to 20x Up to 20x Up to 20x Max no. slices displayedat once 64 16 16 16 IMAGESTORAGE Harddisk,GB 446 146,144 raw data, T4 146,144 raw data, T4 180, 720 raw data, T4 No. online images 260,000 200,000 200,000 160,000 Archival storage CD-R, MOD 4.8 GB MOD 4.8 GB MOD 9.4 GB DVD-RAM PERFORMANCE Minimuminterscan time, sec 0.25 0 0 0 Dynamic scan rate Not specified 200 scans/100 sec 200 scans/100 sec 200 scans/100 sec High-contrast spatial resolution - 0%MTF, lp/cm 16.3 18 18 18 -50%MTF, lp/cm Not specified 8 8 8 Low-contrast res, -mmat %at < =4 rads 5at 0.3%at 2 rads 2 at 0.3% 2 at 0.3% 2 at 0.3% Noise,%at < =2.5 rads 0.29 < 0.5 < 0.5 < 0.5 CORONARYARTERY No Optional Optional Optional CALCIFICATION SCORING DICOM 3.0 INTERFACE Yes Yes Yes Yes RECOMMENDEDROOM SIZE,m 2 24 27 (25 short couch) 27 (25 short couch) 27 (25 short couch) POWERREQUIREMENTS 380-480 VAC, 3-phase, 66-87 kVA 200 VAC, 50/60 Hz, 3-phase 200 VAC, 50/60 Hz, 3-phase 200 VAC, 50/60 Hz, 3-phase

34 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES

. My Opinion INTERVIEWWITH What are yourpredictions for improvement of clinicalmanage- JONATHAN ELION ment of cardiovasculardisease?

. Hospitals are under great pressure these days toreducecostsandimprovequality.Thereare at least three emerging trends that will help in these areas:clinicalpathways that help toformalise our niche in the market (PC-basedimage review),and approach toclinicalcare,performancemeasures that launchedoureffortsintoindustry. that help quantify the effectiveness of our treat- INTERVIEWEE mentsandComputerisedPhysicianOrder Entry J ONATHAN E LION If you had tochoose adifferent (CPOE)systems that assist in managing the orders N EWLY APPOINTED C HIEF M EDICAL O FFICER (CMO), career, what would that be? AGFA H EALTHCARE that implement care plans. Together, these

C O - FOUNDER AND M EDICAL A DVISOR,HEARTLAB . Well,if Ihad it todoall over again,I would approaches canbeapplied todeveloping disease

JLE@HEARTLAB. COM pick the same career! But Iconfess that Ilove management programmes. The areas that are music, especially playing the guitar,and would being addressedmost commonly in Cardiology Tell usabout yourprofessional probably pursue that pathifIhad tochoose adif- includeAcuteCoronary Syndrome (ACS)because of background. ferent career. the seriousness of the clinicalcondition,and CongestiveHeart Failure (CHF)because of expense . I went toBrownUniversity for college and MedicalSchool, trainedin InternalMedicine at the Who hasinspired you most in associated withcaring for this population. University of Wisconsin,andin Cardiology at Duke yourcareer? What areasofmedicalIT will University.Ihavebeen involvedin computers since . Among the many excellent role models and 1968,andcontinued tobeactivein the fielddur- mentors Ihaveencountered, my greatest inspira- impact on the imaging industry ing my medical training. Ibeganmy researchin tion came from my father's sister,GertrudeElion, in years tocome? medicalimage processing in 1983,developing who won the Nobel PrizeinMedicine in 1988 (see . Ibelieve we will continue tosee the elimina- techniques for DigitalSubtraction Angiography, http://nobelprize.org/medicine/laureates/1988/index tion of artificialbarriers that exist between digital DigitalEchocardiography,and“parametricimag- .html). Agentle lady withaninsightfulmind, she images and the rest of clinicaldata.Imaging will ing”(encoding physiologicinformation intoimages helpedme see my way through difficult scientific, continue tobemanagedandmerged withclinical ascolor overlays). Ihavebeen actively involvedin technical,moral,andethicalconcerns. She was datarather thanbeing in aseparatesystem. developing andapplying standards tocardiac alwaysgraciousinacknowledging the contribu- imaging andinformation,serving asco-chair of tions of others,and wasapt tosay,“It’s amazing How canefficiency beincreased severalkey committees including DICOM Working how much you canaccomplish if you don’t care in Cardiology departments? Group1for CardiovascularInformation,Integrating who gets the credit”. . It is agreat challenge tocollect andreport on the Healthcare Enterprise (IHE)Cardiology Planning all of the information related toastudy suchas Committee,andHL7’s SpecialInterest Groupin What hasbeen yourbiggest cardiac catheterisation. Heartlab’s suiteofproducts Cardiology Coding. Ico-foundedHeartlab in 1994 career success? allowsahospital toimplement moreefficient along withBobPetrocelli,anengineer who was . DICOM Working Group1 worked toadapt the workflowsofpatientsandinformation. Insome working in my researchlab. DICOM standard tocardiac imaging,bringing order cases,it is possible toget afinishedandsigned to the chaos that existedat that time withregard report completed within minutes after completion What led you topursueacareer to the variety of proprietary formats that were of the cardiac cath. By feeding reportsdirectly into in healthcare? being usedfor image storage. Wesponsored the aHospitalInformation System,resultscanbe . Ialways wanted tobeadoctor,andnever first demonstration of the use of the DICOM for quickly disseminated toeveryone involvedin the waveredfrom that path. When Ibegancollege,I cardiac imaging in March1995. I wrotesoftware care of the patient.On the imaging side,ourhigh- addedaninterest in computers,andhavecontin- that waslater put into the publicdomain andcre- quality digitalstorage andreview, together with ued topursuebothinterestsever since. Icontinue ated the set of referenceimages andCD-ROM that ourability toprovide this capability on low-cost my clinicalactivities asaCardiologist on alimited were usedby 29 vendors toexchange anddisplay personalcomputers and workstations helped to basis,andhavehad the goodfortune tobeable to images from cardiac catheterisation andechocar- movecoronary angiography from film todigital. combine my clinicaland technologicalinterests. As diography.Ina very realsense my workon this Weare seeing asimilar transformation asechocar- part of my workon the DICOM standard, Bob demonstration project began the DICOM erain car- diography moves from videotape todigital. We Petrocelli andIrecognisedanopportunity toestab- diac imaging,andcreated the market into which hope tosee asimilarshift in EKGmanagement as lish acommercialpresence tofill amuch-needed Heartlab sells. wemovefrompaper-based todigital workflow.

36 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES

INTRODUCTION TO ❚❚❚ HEALTHCAREREFORMS THE DANISH IN DENM ARK D enm a rk HEALTHCARE SYSTEM F o c u s C o u n t r y

InDenmark thereis free and equalaccess tomost healthcare services, the pro- vision andfinancing of whichis mainly public.The Danishhealth- care sector is decentralised, with the counties being responsible for hospitals,generalpractitioners,practising specialists,etc.

HealthcareReforms: ' asimplifiedandefficient publicsector Implementing Changes ' clearly definedresponsibilities andno “grey zones” The Danish government believes that thereisaneed to between the publicactors AUTHOR reform the frameworkfor public tasks andpublicservices, ' increasedcitizen’s involvement andimprovedlocaldemoc- A SGER H ANSEN including the healthcare system. Therefore,from the expect- racy D ANISH A SSOCIATION OF edcommencement of the reform in 2007, the present health- ' less red tape,fewer barriers andmoreoptions H OSPITAL M ANAGEMENT care services will also beaffected.Most current initiatives ASHAN@ focusonhospitals andinpatient care.While further structur- The publichospitalandhealthcare services are still tooffer GENTOFTEHOSP. KBHAMT. DK alchanges,possibly associated with the greater role of the equal,open andfree access to the citizen andensure optimal privatesector,are discussed, according togeneralpolitical treatment of people,independent of residentialmunicipality. consensus, the Danish healthcare system will remain commit- Professionalexpertise is tobeconcentrated, course of treat- ted to the welfare ideals of tax financing and universalaccess ment is tobecoherent andextra workis toberewarded. tohigh quality healthcare.In 2004, the Danish Government The Government’s proposalcontains the following main lines proposedanew structure of the Danish publicsector,includ- for hospitalandhealthcare services:The present regional ing the healthcare services. At the beginning of 2005 the level (14 counties andCopenhagen HospitalCorporation) are Government put forwardaproposalfor suchareform,sched- tobeabolishedandreplacedby 5healthcare serviceregions uled to take effect from 1st January 2007.The proposed withdirect election of politicalrepresentatives for 4 years, reform is toreplace the localgovernment reform of 1970. who are responsible for hospitals,generalpractitioners and other healthinsuranceschemes as well aspsychiatric treat- It is the ambition of the Government todevise the best pub- ment.The governmentalbody for eachregion will becalled licsector for the solution of tasks asclose to the citizen as The RegionalCouncil and the number of members is fixedat possible,andensure the best valuefor taxpayers’money. 41. Eachregion will includeabout one million citizens. The Government wishes tonot only reduce the number of The regions will have uniform conditions for the solution of regions andmunicipalities but tocarry through a visionary tasks within the healthcare sector.Healthcare services will andfuture-orientedreform of the tasks themselves. The aim primarily befinanced through astateblockgrant basedon is todevise apublicsector that will solve the tasks in objectivecriteriafor expenditure need(approx. 75%),a Denmark in asuperbmanner for many years ahead. smaller stateactivity pool (5%),andlocalfinancing that is a basiccontribution (10%) andanactivity-relatedgrant (10%). Todo this, the Government is set on aone-tier publicsector The number of direct personnel taxation levels will therefore close to the citizen characterisedby: in the future bereducedfrom three to two(stateandmunic- ' morequality for the money ipalities). Inorder tofinance the main part of the regional

38 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Country Focus Denmark ❚❚❚

andlocalhealthcare expenditure, the stateimposes ahealth- for prevention,care andrehabilitation that donot take place care contribution of 8% basedon the local tax base. The pro- during hospitalisation. The municipalities shouldbeable to ceedsare paid to the state, whichdistributes the funds to findnew solutions especially within prevention andrehabili- the regions andmunicipalities. tation,e.g. in the form of healthcentres. Due toco-financ- ing, the municipalities will become moreinterestedin initiat- The proposalalso includes anenlargedresponsibility of ing prevention andencouraged torelieve the pressure on the healthcare for the state. The NationalBoardof Health will be healthcare service. Reducing unnecessary hospitalisation and responsible for providing strong nationalco-ordination and ensuring that the treatedpatientsare dischargedasquickly improvedconcentration of the most specialised treatment and aspossible will beaccomplishedby making the current care the centralhealthcare authorities will beresponsible for ensur- rate, which the counties charge the municipalities for treated ing systematicfollow-uponquality,efficiency andITapplica- patients,obligatory bothfor somaticandpsychiatric tions in the healthcare servicebasedon common standards. patients. The approximately 100 new municipalities will beresponsible

The DanishSociety of Radiology has been in operation since1921,andcounts over 500 activemembers. Approximately every certified radiologist in the country belongs to the society.The aim of the society is topromote science,education andcollaboration inside the radiology profession. Our society is activein all areas of radiology, witha specialemphasis not only on the education of radiologists but alsooncon- tinualpost-graduateeducation. Wearemembers of the EuropeanSociety of Radiology (ESR), InternationalSociety of Radiology and the NordicSociety of MedicalRadiology.Ihaveoccupied the

position of President of the society for the last three years,and will come to the endof my termin AUTHOR January 2007.Ihavebeen activein radiology sinceIobtainedmy specialist competencein1989,and D R .B IRTHE H ØJLUND B ECH presently workas aconsultant radiologist in Department of Radiology in the MusculoskeletalRadiology R ADIOLOGISK AFDELINGEN X, section at Rigshospitalet,Copenhagen. 3023,RIGSHOSPITALET, K ØBENHAVN

FORMAND@ DRS. DK Another way in which wecollaborate with the NationalHealth DANISH Boardis in anadvisory capacity on suchissues as the edu- cation of radiologists. Oursociety provides theoretical train- SOCIETYOFRADIOLOGY ing courses andadvises on the curriculum. About 24new radiologistsare certifiedevery year.

PROMOTINGRADIOLOGY Eachresident followsacourse that lasts 6.5 years, the first THROUGHOUT DENM ARK 18 months of whichisspent in generalmedicalandsurgical training (basiceducation). This is followedby a yearin which they are introduced to their specialty area.They then pick Probably ourmost significant responsibility is ourrole as their ‘major’,or main subject,andout of eachgroupof advisory consultant to the NationalBoardof Health. Wecol- trainees,andmore than 20 every year will choose radiology laborate with them in many ways,andone of the main tasks as their subject.The emphasis in Denmark,in radiology train- in the year tocome,is toprovideevidence-basedrecommen- ing,is of course on clinical work. However,over the course dations of the placement of variousimaging procedures,for of that education,over 210 hours will also bespent involved example specialinterventionalproceduresconsidering the in theoretical training toback this up,in eachof the differ- number of steps that are needed toperform asafe proce- ent subspecialties. As withmany countries in Europe, we dure.This issueisacurrent one now that Denmark is reor- havenofinalexams for trainees in radiology.Rather, we use ganising the healthsystem,reducing the number of itscoun- the recordsof their clinical workin the radiologicaldepart- ties. The NationalHealthBoardis todecide whichhospital mentsandof their centralised theory tests toget anoverall shouldprovidespecialisedprocedures. We will bemaking picture of how each trainee is progressing. The National ourrecommendations on how tocentralise eachof the spe- Boardof Healthhasestablishedasystem withinspectors cialisedmodalities andinterventionalproceduresand where who have the task of evaluating the departmentsinrespect these shouldbehoused.This will no doubt continue tohave toeducationalstandards. implications for the provision of healthcare in Denmark for a long time tocome,andoursociety aims tomonitor the sit- Weare also actively involvedin post-graduate,continuousedu- uation closely in order toassure that weare organisedin the cation in definedsubspecialties. Oncea yearacourse is held best possible way tomeet the coming challenges. over twoandahalf daysondifferent subspecialties. *

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 39 ❚❚❚Country Focus Denmark

CONTINUED * Working Groups have with the referring doctor,andsecurity issues, urgently D ANISH S OCIETYOF One of our various working groups that actively focuson the need toberesolved.Other working groups within the Society R ADIOLOGY different hot topics that are affecting imaging professionals are making recommendations for diagnosis of different dis- bothinDenmark andacross Europe is ourspecial working eases,for example how tochoose the appropriatediagnos- groupon teleradiology.Hereat the Rigshospitalet weare ticmodality and treatment for eachpatient. providing teleradiology facilities for hospitals across the country including Greenlandand the Faroeislands that have The Society holdsanAnnualGeneralMeeting in order to needof ourservices in order toproducereportsonimaging uniteitsmembers anddiscuss the most pressing issues of exams. Wegenerally receiveimages related todifficult or the day.The last meeting, which washeldin Odense, 25-27 specialisedproblems that requireourservices. In this way, January 2006,covered the activities of eachof these groups, wehaveagoodideaon apracticallevel,of the types of as well as the main areasofradiology,film reading sessions, issues andconflicts that come intoplay in running this kind especially for the younger radiologists,ascientificsession of service. For example,problems withstandardisation,legal andasession focusedon the politicalissues raisedby problems,image quality etc.Some of the main questions our Denmark’s politicalreorganisation of the healthsystem. working groupaddresses,suchas what contract weshould

In this article,I will present one of Copenhagen’s largest andbusiest diagnostic radiology departments,and discuss the problematic situation regarding financialadministration of healthcareinDenmarkas it affects diag- nostic radiology.Firstly, the University Hospitalat Herlev itself is one of the major hospitals in the Copenhagen area, withapproximately 800 beds.It offers oncologic treatment tomore than1.2million inhabitants.All abdom- inal specialties (SurgicalandMedicalGastroenterology,Urology,Nephrology andGynaecology)arefacilitated. As well as orthopaedic surgery, rheumatology,endocrinology andplastic surgery, the hospitalprovides services within cardiology,pulmonology,infectious diseases andgeriatrics as part of internalmedicine services.

MR scanner, twoopen MR scanners (0.23Tand 0.6T)and two COPING WITH closedMRscanners (1.5T), wereinstalledanda 3Tscanner INCREASED DEMAND is expected tobeinstalledby the endof 2006.These instal- lations haveled toanalmost five times increase in the num- ber of examinations performedsince 2001. However,despite DEPARTMENT OF DIAGNOSTIC this increase, waiting times havenot been reduced. The Department has thirty-one examination rooms. Asa RADIOLOGY AT result of latemodernisation, the department hasjumped directly toDigitalRadiology (DR)fromanaloguefilms. Atotal of eight DR rooms are available for conventionalradiography COPENHAGEN andafurther fourfluoroscopy rooms. The breast imaging AUTHOR team, with three double rooms withamammography andan

P ROF .H ENRIK T HOMSEN ultrasound unit respectively are the only analog part of the UNIVERSITY department,being built in 2000, when digitalmammography C HAIR OF D IAGNOSTIC R ADIOLOGY wasnot yet consideredadequateand withabudget that was apoliticalcompromise. At the University Hospital the PET/CT- C OPENHAGEN U NIVERSITY HOSPITAL H OSPITAL,HERLEV , scanner is runasajoint venture with the department of D ENMARK ClinicalPhysiology andNuclearMedicine, whichare inde-

HETH@ The Department of DiagnosticRadiology is the thirdlargest pendent specialties in Denmark. HERLEVHOSP. KBHAMT. DK department in Denmark withregards tonumber of examina- tions, with the majority of the workload consisting of scan- InDenmark, the government hasissuedaguarantee toall ning. Over the last three tofour years, the number of CT patients withsigns of or confirmedlife-threatening disease scans performedhasalmost tripled; the department has that they have the right tobeexamined with two weeks of three scanners (one 4-slice, two16-slice) andin 2006 two 64- their referral. Other patientsmust beexamined within eight slicescanners will beinstalled.MR in particularhasseen an weeks. Otherwise the patient canchoose any privateclinicor exponentialincrease in number of exams performed.Anew hospital, whichhasacontract with the union of counties MR centre (the largest in Denmark) wasbuilt in 2001. Atotal who must fund the examination. The endresult is that guar- of 5MR scanners,including one dedicatedextremity (0.2T) antees havebeen unfulfilledin most areas,made worse by

40 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Country Focus Denmark ❚❚❚ the fact that oncologicpatientsare obliged tohave their dis- million inhabitants. The current government hasallowedpub- ease controlledby aparticularscanner according torecom- lichospitalowners toinvest a totalfigure of 40million Euro mendations from the WorldHealthOrganisation (WHO). bothin 2005and 2006 in new CT,MRandPET/CT scanners. The money hasbeen used toreplaceoutdatedscanners,but MedicalTraining in Denmark also installation of morecapacity has taken place. Both teaching andresearchare taken very seriously.In Denmark, universities are only responsible for pre-graduate Reforming Healthcare training. Postgraduateorspecialist training is taken care of by For decades now,Denmark hasoperated within three politi- the Ministry of HealthandNationalHealthAuthorities. The callevels. The Counties (secondlevel) havebeen largely University of Copenhagen hasone of the biggest medicalfac- responsible for healthcare since1970.In 2005 the parliament ulties in Europe regarding training of medicaldoctors. Yearly, decided toreform the structure,meaning that communes will 700 to800 studentsare immatriculated.Access is not free, bedividedintolarger segmentsofmoreorless 30,000 inhab- with uptake basedon grades in high school. After six years itantsand will beinvolvedin aminor portion of healthcare training, twomandatory clinical years (psychiatry,general andcanissue taxes. Instead of the fourteen counties andcen- practitioner,surgery andmedicine) are followed.In tralCopenhagen (the current hospitalowners) there will be Copenhagen the first two years are allocated to theoretical fiveregions on January 1st 2007, who are not entitled toissue teaching (anatomy,physiology,biochemistry etc.) whereas the taxes. 80-90%of their income will come from the government following three years are mainly clinical. Postgraduate train- with the rest made upby the communes. This is aclearcon- ing in radiology takes five years. Twoapplications must be firmation of the tendency of the government and the parlia- submitted: one for the first yearandone for the last four ment tointervene moreandmoreinhealthcare issues. years. Thereare no boardexaminations,but acheckbook for Regulations regarding hospitallaw thirty toforty years ago skills/competences hasrecently been introduced. were very limited: the county took care of hospitalcare.To dateit is moredetailedand through financialcontrolfrom the Imaging in Denmark government the new regions havelimitedfreedom topriori- The population of Denmark is approximately 5.5m inhabi- tise. Only time will show whether the reform resultsinan tants. Denmark hasalow level of imaging proceduresper improvement in healthcare. inhabitant,independent of age, withonly 0.7 examinations per year. The number of examinations is presently increasing The current situation hasnot been adequate. Too many deci- by approximately 5%. However, within the fieldof oncologic sions were taken due tolocalinterestsrather than to the ben- imaging the growthrateisapproximately double this. 98% of efit of patients. The horizon for planning hasonly been four the hospitalserviceinDenmark is socialised, paid through years (the election period). Major reforms (e.g. closing asmall high taxes. All citizens have the right toaccess to treatment. hospitalormerger of departments) weregenerally decided Generalpractitioners working in privateclinicsare reimbursed upon right after elections. During the recent years it hasbeen for patient serviceby the publicsector.Anincreasing number obvious that the close connection between voters andpoliti- of Danes take out healthinsurancepolicies or are coveredby cians in small counties didnot result in much-neededdeci- their employers. Withregards toradiology,generalpractition- sions for example,cancer surgery wasallowedin too small ers refer their patients to the radiology department at the units,andCT-scanners wereinstalledin small hospitals,but localhospital. However, thereare twoexceptions: not useddaily. 1) IncentralÅarhus thereisasingle privateclinic withacon- tract with the county Conclusion 2)In the centralcommunes of Copenhagen all radiology Inconclusion,it is my opinion that the larger regions should exams done for generalpractitioners are providedby limit the influenceoflocalinterestsandconcentrateon the twelve tofourteen privateclinics,consisting mainly of con- bigger picture.In 2000 the government gaveall counties an ventionalradiology and ultrasonography. extra 26million Euro toinvest in scanning capacity for onco- logicpatients,despite the fact that only six of the fourteen Recently anagreement between the commune andprivate counties andcentralCopenhagen haveoncologiccentresfor clinicshasbeen reachedregarding reimbursement for MRI and treatment of cancers (radiation therapy andchemotherapy). CT.Nocommune or county outsidecentralCopenhagen hasan Nomoney wasinvestedin scanners for oncologicpatients, agreement with these clinics. Some independent imaging cen- but rather in particularfor MR scanners at small localhospi- treshaveappearedduring the last few years, taking care of tals. Aclose watchshouldbekept toensure that new health- patients withhealthcare insuranceand those who the public care reforms allow for the increase in the number of radiolog- radiology department are obliged tofacilitate within the guar- icscans andexaminations performed, particularly in oncolo- anteedeight week period.Thereare approximately eight pri- gy, tobemet by publichealthcare facilities,and toensure vateMR unitsand twoCT scanners. In the publicsector there that decisions benefit not just smaller areasbut the nation as wereeleven MR scanners and thirteen CT scanners per one a whole.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 41 ❚❚❚Country Focus Denmark

The Aarhus University Hospitalis responsible for the clinicaleducation of more than 250 medical students per year.It covers basicandclinical researchinmore thanfifty localor centrallaborato- ries spread over seven hospitals. 323 PhD students were registeredat the Faculty of Health Sciences in 2004. A strong partnership withnationalandEuropeaninstitutions enables us topur- suecutting-edge researchactivities.Infact,over 1,100 peer-reviewedpublications areproduced annually by the University of Aarhus,comprising 1.5-2%of the world’s publications in health sci- ence. Due to the fact that in Denmark,it is planned that clinicaldepartments and researchactivi- ties will behousedin one enlargedhospitalfacility, we now face the challenge of managing our widespread activities in aninnovative way.The University Hospital is managedby aBoardof Directors from the University of Aarhus andby regionalcounty governments.The edu- cation/researchbudget includes 15m Euro, withabout 7mEuroallocated to researchanddevelopmentalactivi- ties.45m Europer year is grantedfor researchfrom privateorganisations. MR RESEARCH AT AARHUS UNIVERSITYHOSPITAL CROSS-DISCIPLINARY MANAGEMENT POLICIES ments,molecularimaging and therapy is directed towards focused therapy basedon particles designedfor targeting specificpathologic tissues. The techniquerelays the latest It is the main strategy of the Centre toprovideabroad plat- achievements within non-invasivein-vivoimaging methods, form of MR techniques, thus welcoming abroader spectrum nano- andgene technology,immunology,molecularbiology, of scientificspecialists withacommon interest in applying oncology andbiomedicalengineering. New developmentsin MR to their fieldsofresearch. Imaging modalities includeCT, these fields will result in moreeffective treatment regimes PET/CT,Ultrasound, GammacamerasandIRopticalimaging. andpreventivemeasuresfor diseases like cancer,diabetes, Wealso havefifteen MR scanners, three tofourof whichare obesity,atherosclerosis anddegenerativediseases of aging. useddaily for research. Being situatedin aHospital,of Thusourcross-departmentalapproach toourresearch course,relevant clinicalresearchprogrammes havehigh pri- enables a wider fieldof possible long-term benefitsina wide ority, whichcanbeseen in the themes of ourresearch range of diseases. AUTHOR groups:MolecularImaging in Cancer,Neurophysiology/ H ANS S TØDKILDE- Neuropsychology,CardiovascularMRI, Kidney Functionality, Hereat the ResearchCentre, weare dedicated todeveloping J ØRGENSEN etc.Ourcross-institutionalorganisationalmodel securesa new chemo- andradiotherapy regimes implementing molec- MR R ESEARCH C ENTRE, wide variety of disciplines, with the most up-to-dateclinical ularimaging-guided treatment that specifically targetsabnor- A ARHUS U NIVERSITY H OSPITAL,DENMARK regimes. In the experimentalandclinicalradiologicaldepart- malcells. Importantly,molecularimaging has the potential ments,facilities allow for cross-disciplinary activities for for localising all malignant cells of aspecific type,including HSJ@ MR. AU. DK example,engineers,physicists,chemists,psychologistsand even small remotemetastases. When restricting anticancer researchers, who work together under acommon goal. therapy tomalignant cells only, the debilitating sideeffects of conventionalchemo- andradiotherapy will bereducedand MR Research:UnifiedResearch amorecomprehensive therapy that will improve virtually Strategies every clinicalandquality-of-life marker becomes available. In InDenmark, we try toremain on the cutting edge of oursci- addition,molecularimaging and therapy offers navigational entificresearchendeavours. For example, within MR assistancefor targetedproceduresfacilitating uniquepreci- research, the main focusisonquantification of organfunc- sion in biopsy procedures. tionality of the heart,brain,liver,kidneysandmusculoskele- talsystem. Inoncology, this includes quantification of viabil- Conclusion ity in tumourcells subjected to variousanti-tumourand Eachof these steps requires amulti-disciplinary approach tumour vasculature-disrupting therapies. The MR areais pur- that resultsnot only in asuperior level of researchanda suing unifiedresearchstrategies. One of these is “Molecular wider target groupofresearchsubjects,but that attracts the Imaging andTherapy:design of intelligent molecules for foremost expertsin the field, thusenabling the widest pos- combinedmagneticresonanceimaging andcancer treat- sible implications for improving healthcare anddisease con- ment”. Basedon new interdisciplinary researchachieve- trolinEurope.

42 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES Country Focus Denmark ❚❚❚

BRAIN RESEARCH AT AARHUS PETCENTRE

in vivoat the highest scientific FOCUSONPET andclinicallevel. Ouraim remains toconduct physiological RESEARCH ACTIVITIES andpathophysiologicalresearch AUTHOR in animals andhuman volun- P ROF .A LBERT GJEDDE IN DENM ARK teers,and to undertake diagnos- P ROFESSOR OF M EDICAL tic tests whenever PETis likely to N EUROBIOLOGY givea usefulanswer.The

U NIVERSITYOF A ARHUS The PositronEmission Tomography (PET)Centre of the researchcomponent accountsfor 80%of the resources of the centre, while the diagnosticproceduresare supported D ENMARK AarhusUniversity Hospital wasestablishedon October 20th, 1993,asajoint activity supportedby the County of Aarhus, by the remaining 20%. Although the centre hasfivemain ALBERT @ PET . AUH . DK the MedicalSchool of AarhusUniversity,and the Medical areasofresearch:cardiology,neurology,psychiatry,hepa- ResearchCouncil of Denmark.The centre is adepartment of tology andoncology, this article aims topresent the activ- the AarhusGeneralHospitalandalaboratory of the institute ities of the centre in relation of neurologicalresearch. of ExperimentalClinicalResearchofAarhusUniversity.The centre wasalso the seat of anMRC(Denmark)Chair of brain Weat the AarhusPETCenter are supportedby authorities, research until the endof 1999. The centre occupies the bot- funding agencies,andcolleagues from around the world. tom floor of the neurology house of AarhusGeneralHospital, Diversifying oursources of support hasenabled the centre and uses cutting edge imaging equipment awardedby the toexpanddespitebudgetary cutsexperiencedby other sec- KarenElise Jensen Foundation. tors of the Danish healthcare system. More thanhalf of the support arises from the ResearchInitiativeofAarhus Our ResearchActivities University Hospitals. The rest is collectedfrom numer- The theme of brain researchat the PETCentre is the neuro- oussources,including the MedicalResearchCouncil plasticity of predictivecoding in the brain. By predictivecod- of Denmark, the EuropeanUnion Biomedical ing wemean the ability of the brain topredict the meaning ResearchProgram, the Danish Heart of present eventsand the coming of future eventsand to Association, the Novo-Nordisk Foundation, restructure itself on the basis of the success of these predic- the Parkinson society, the Danish Medical tions. The researchiscarriedout at the PETCentre’s facilities Association,andseveralprivatefunds. This at the AarhusUniversity Hospital under the dualauspices of enables us tocontinue tomaintain ourcut- the AarhusUniversity Centre of Functionally Integrative ting-edge researchand toensure that we Neuroscience(CFIN),establishedby acentre of excellence stay on the forefront of technology. grant from Denmark’s NationalResearchFoundation,and the GSK-AarhusInstituteofMolecularImaging (GAIMI). The Collaborativeeffortsin whichour researchincludes bothhumanandanimalstudies designed centre playsa valuable role toreveal the interactions among neurotransmission,energy include the NeuronalXeno- metabolism andcognition in the mammalianbrain. Transplantation (NeXT),Micro- DAB (microvasculardemen- The PETCentre conductsinvestigations of the relation tia),andCOSTAction B3 between energy metabolism andconsciousness in the mam- projectsof the European malianbrain by recording the changes of energy metabolism Union,and the Center of andconsciousness under pharmacologicalandother manip- DrugDesign andTransport ulations. In the last year, the PETCentre conductedanum- (CD2T)andFREJA projectsof ber of PETstudies focusedon the questions raisedabove. the Danish MedicalResearch Council. Through this weare Financing Issues: activeonaEuropeanlevel and Diversifying our Resources can work withother leading The centre’s mission is toexplore the pathophysiology of experts withanactiveinterest in disease mechanisms by means of experimental tomography the field.

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 43 ECR 2006 S C I E N T I F I C P R O G R A M M E the world, some of them establishednames,others Congress Preview This year’scongress attracted the largest number of young andrising stars. submittedscientificpapers yet.Fewer thanhalf of Inaddition toprofferedpapers andscientificexhibits, these submissions wereaccepted.Due to the exceed- thereisagreat variety of invitedpresentations, ingly well-coordinatedeffortsof including new horizons andspecialfocussessions EUROPE’SLEADING RADIOLOGYCONGRESS eminent radiologistsfromacross andhands-on workshops. Twoof the highlightsare Europe in itspreparation, the con- the new comprehensivecategoricalcourses on the gress reaches greater heightsof staging of cancer andon thermal tumourablation,as This year’s EuropeanCongress of Radiology (ECR) scientificachievement every year. well asafoundation course on musculoskeletalradi- takes placeMarch 3 – 7 2006,in Vienna, Austria.It ECR 2006 will offer excellent ology.The latter course will includeanother ‘ECR first’ will be the first ECRheld under the auspices of the reviewsofstate-of-the-art practice –aself-marking electronicexamination that will allow EuropeanSociety of Radiology (ESR), uniting all withglimpses of the future.The sci- participants toassess what they havelearned.In major organisations in this fieldof medicine. entificsessions will bepresented addition, there will be‘ECR meets’ sessions with Therefore,in addition to taking part in a scientific by many of the best radiologistsin Russia, Singaporeand the UnitedKingdom. Lectures endeavour,attendees will bepart of a truly historic development in European radiology. O P E N I N G H O U R S R E G I S T R A T I O N ThursdayMarch 2 09:00 –19:00 O N - S I T E R E G I S T R A T I O N A T T H E FridayMarch 3 07:00 –19:00 C O N G R E S S V E N U E Saturday March4 07:00 –19:00 AustriaCenter Vienna SundayMarch5 07:00 –18:00 Bruno Kreisky Platz 1 MondayMarch 6 07:00 –18:00 A–1220 Vienna, Austria TuesdayMarch 7 07:00 –14:00

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44 P ROMOTING TEAMWORKACROSSDIFFERENTDISCIPLINES in these sessions are being deliveredby world- technologies in radiology andsurgery for clinical ' New IHE integration profiles andDICOM informa- renownedradiologistsandprovideaglimpse of cur- application fields,suchas: tion objectsandservices toenable smoothcom- rent practicein the nations involved. ' MedicalImaging,e.g. CT,MR, US, SPECT,PET,DR, munication between radiology andsurgery MolecularImaging,andVirtualEndoscopy ' SurgicalPACS in the operating room aspart of a S O C I A L P R O G R A M M E ' Image Processing andDisplay hospitalIT infrastructure Even though the ECR by now is one of the largest ' Hospital-widePACS andTelemedicine ' Organpreserving image guidedablation procedure internationalimaging congresses in this discipline in ' Computer Applications for e.g. Neurosurgery,Head Europe it not only offers anexcellent scientificpro- andNeck,Orthopaedics,EarNose andThroat, It appears that moreandmoreof the “high impact” gramme,but also anoutstanding socialone. Vienna CardiovascularandThoracoabdominalSurgery,and innovations are being madeinnetworkenvironments. fulfils anew itsreputation asculturalcapitalof the Plastic/ReconstructiveSurgery GeneralIT examples of this trendare the Internet, world, providing aboundless variety of artistic ' Image GuidedTherapy open sourcedevelopmentssuchasOsiriX, the Insight endeavours. Ofnoteisaspecialareadedicated ' SurgicalRoboticsandInstrumentation Toolkit,Linux as well asstandardactivities suchas Wolfgang AmadeusMozart's 250thbirthday,celebrat- ' SurgicalNavigation andSimulation DICOM, e.g. DICOM in Surgery. edby the city of Vienna, itscitizens andguests. ' CAD for Breast,Prostate,Chest,Colon,Liver,Brain, SkeletalandVascularImaging These networkedenvironmentsmay take the form of inter-institutionalproject groups or open consortia. The response to the Call for Papers for CARS 2006 in They provideabasis for interdisciplinary cooperation F U R T H E R I N F O R M A T I O N Osakahasbeen very encouraging. Altogether,497 or realand/or virtualmeeting places that allow their ECR OfficeVienna abstracts weresubmittedfrom 34countries. With this members tocooperate,collaborateandinter-operate. Neutorgasse 9/2a level of submissions,CARS 2006 will provideahigh- During the past 20 years, the CARS Congress has AT –1010 Vienna ly professionalprogramme for the participants. The been establishedasanopen consortiumandasa T: (+43-1) 533 40 64-10 informalfederation of societies andcongresses of hubin anetworkofscientific/medicalorganizations. F: (+43-1) 535 70 41 CARS 2006 in Osaka(ISCAS, CMI, CAD, andCAR)con- It encourages andparticipates in joint events with [email protected] tinues toprovide the necessary coopera- these organizations in order toprepare the groundfor www.ecr.org tiveframeworkfor advancing the devel- innovativeactivities. These collaborativepartners opment andapplication of modern com- seek innovation andprogress in the fieldof CARS by puter assisted technologies in healthcare. bringing together the “right mix”ofpotentialinnova- These fourorganisations with their spe- tors andlead users,selectedfrom aninterdisciplinary cificscientific/medical topicscomplement andinternationalcommunity. CARS 2006 one another.They givea worldwidelead Computer assistedRadiology andSurgery in interdisciplinary andinternational The CARS Congress is closely linked to the cooperation, which will be the foundation InternationalJournalofCARS.The Journal will present JUNE 28–JULY1, 2006,OSAKA, JAPAN of healthcare in the 21st century. resultsfrom the CARS fieldsinselectedproffered JOINT CONG RESSOFCAR/ISCAS/CMI/CAD papers,review articles,short communications and WWW.CARS-INT.ORG Looking at innovations in the fieldof commentaries. The journalisinafortunateposition, CARS asameans tochange processes in asit candraw from the disciplines of CARS from a 20 year tradition of itscongress. CARS hasalso along The InternationalCARS Congress provides aforum healthcare, wherecan weexpect original research tooccurin the nearfuture? standing relationship with the prestigiousJournalof toclose the gapbetween diagnosticandinterven- Examples of R&D areasfrom whichinno- AcademicRadiology (AR),USA.The tradition of CARS tional radiology, surgery andinformatics and to vations may bederivedare: toencourage andinvitesubmission of manuscripts to encourage interdisciplinary researchanddevelop- ' Computer assistedimaging methods AR withahigh clinicalandeducationalcontent in ment activities in aninternationalenvironment. andassociated workflows that matchand radiology will also befollowedin the future.The evo- enhance the skill levels of healthcare lution of CARS asacongress andjournalandasa Toincrease the valueofhealthcare for citizens, the professionals facilitator of innovation is animportant contribution focusof the Congress is on providing balancedand ' Radiologicalandsurgicalassist systems in oncolo- tomedicine andis expected toprovidebenefit on a in-depthinformation on new diagnosticand thera- gy incorporating novel information sources,e.g. worldwidebasis to the R&D community and to peuticprocesses. This includes resultsfrommultidis- molecularimaging patients. ciplinary R&D efforts,providers' experiences,patient ' Surgical workflow peer-to-peer repositories of outcomes,economicandmanagement considera- “goodpractice” surgicalprocedures C O N T A C T tions,as well asscientific/medical validation results. ' Intelligent CAD systems minimizing false-positives, Heinz U.Lemke,PhD It canbeexpected that the resulting awareness by for example by using acomprehensiveimaging CARS Organiser users andproviders will speed up the acceptanceof repository ResearchProfessor of Radiology, CARS intoclinicalpractice. The main emphasis of the ' IT methodsfor seamless integration of the EMR University of Southern California, LA,USA presentations of the CARS Congress is on information intoperioperativeinformation handling [email protected]

IMAGINGMANAGEMENT :THE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE 45 Author Guidelines ^ for Imaging Management

CONTENT ' one contact name for correspondence lowedby "et al." and the yearofpublica- IMAGING Management, the official voiceof andane-mail address whichmay bepub tion. Multiple citations shouldbeseparated the EuropeanImaging Initiative, welcomes lished with the article; by asemicolon,andlistedin alphabetical submissions from qualified, experiencedpro- ' acknowledgementsofany connections order. fessionals activein the imaging industry, withacompany or financialsponsor; Example of within text citation:(Sains 2004; related technology companies andmedical ' authors are encouraged toincludecheck Sains andMiller 2002;Miller et al. 2003). healthcare professionals withaninterest in lists, tables and/or guidelines, whichsum imaging-related topicsand themes. Weare marise findings or recommendations; The format for listing references in submit- particularly interestedin articles focusing on ' references or sources,if appropriate,as tedarticles shouldfollow the Harvardrefer- management or practiceissues and therefore specifiedbelow. encesystem. Example of standardjournal accept scientificpapers withaclearconnec- reference:Sydow Campbell,K.(1999) tion to these areas. Articles must be written IMAGES "Collecting information; qualitativeresearch by independent authorities,andany sponsors Main authors are invited tosupply aportrait methodsfor solving workplaceproblems", for researchnamed.Oureditorialpolicy photofor publication with their article,as Technicalcommunication,46 (4) 532-544. means that articles must present an unbiased well asother images and visuals. This and Readers will beprovided withane-mail con- view,andavoid‘promotional’ or biasedcon- any other relevant images for publication tact for references, which will bekept on file tent from manufacturers. withanarticle shouldbesent by e-mail as andsuppliedon request.Authors are separatefiles (only high resolution images responsible for the accuracy of the refer- SUBMISSION GUIDELINES with 300dpi) and their order of placement in ences they cite. Authors are responsible for all statements the article must beclearly indicated.Only madein their work,including changes made the electronicformats _.tif_ or _.jpeg_ can ACCEPTANCE by the editor,authorisedby the submitting be usedfor images,i.e. not Microsoft Word It is at the discretion of oureditorialboard author.The text shouldbeprovidedasa or PowerPoint.Images must benosmaller toaccept or refuse submissions. We will worddocument viae-mail toeditorial@ than9cm x 9cmat 100%scale. Only images respond tosubmissions within four weeks of imagingmanagement.org. Please providea meeting these specifications canbepub- receipt.Wereserve the right torevise the contact e-mail address for correspondence. lished.Ifanimage hasbeen published article or request the author toedit the con- Following review,arevised version, which before,permission toreproduce the materi- tents,and topublish all textsinany includes editor’scomments,is returned to almust beobtainedby the author from the EuromedicalCommunications journalor the author for authorisation. Articles may be copyright holder and the originalsource related website,and tolist them in online amaximum 700 wordsper publishedpage, acknowledgedin the text,e.g. © 2004 literature databases. but may include up to1,500 wordsin total. DervlaSains. For further details or torequest acopy of STRUCTURE FORMATFOR REFERENCES the 2006 editorialplanner, with topicsand Article textsmust contain: Please use the Harvardreferencesystem. focusareasincluded, please email editori- ' names of authors withabbreviations for Citations within the text for asingle author [email protected]. the highest academicdegree; referenceshouldinclude the author surname ' affiliation:department andinstitution, and yearofpublication; for acitation with Thank you, city andcountry; twoauthors includebothauthor surnames The IMAGING Management Editorial ' main authors are requested tosupply a and yearofpublication; for more than two Team portrait photo(see specifications below); authors,include the first author surname fol- Subscription Form for Imaging Management

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MedicalDoctors (respondbelow) Non-physicianprofessionals (respondbelow) All respondents reply to the questions below 1. What is youroccupation? (checkonly one) 1c.What is youroccupation? (checkonly one) 2.In what type of facility do you work? (checkonly one) ❏ DiagnosticRadiologist Administrator/Manager: ❏ Privateclinic ❏ Other Physician(please specify) ❏ Radiology Administrator ❏ Hospital(checknumber of beds) ❏ Radiology Business Manager ❏ More than500 beds 1a.What is yourradiology sub-specialty?(checkonly one) ❏ PACS Administrator ❏ 400-499 beds ❏ GeneralRadiology ❏ 300-399 beds ❏ Neuroradiology Executive ❏ NuclearMedicine ❏ Chief Information Officer / IT Manager 3.With what technologies or disciplines do you work? ❏ Vascular&Interventional ❏ Chairman / Managing Director / ExecutiveDirector (checkall that apply) ❏ NuclearRadiology ❏ Chief FinancialOfficer / other executive titles ❏ DiagnosticX-ray ❏ CardiovascularDiseases ❏ NuclearImaging ❏ PaediatricRadiology Other ❏ InterventionalRadiology ❏ Other (please specify) ❏ MedicalPhysicist ❏ CT ❏ Academic ❏ Ultrasound 1b.IamChief of my Department ❏ Chief Technologist / Senior Radiographer ❏ MRI ❏ Yes ❏ Manufacturer ❏ Mammography ❏ No ❏ Business Consultant ❏ Bone Densitometry ❏ Distributor / Dealer ❏ PACS/Teleradiology ❏ Cardiac Imaging ❏ PET ❏ Echography ❏ Angio/Fluoroscopy ❚❚❚ Agenda Key Seminars &Conferences

MARCH 2006

03-07 EuropeanCongress of Radiology (ECR) MAY 2006 PUBLISHING HOUSE VIENNA,AUSTRIA E UROMEDICAL C OMMUNICATIONS NV 28, RUEDELA L OI www.ecr.org 15-17UK RadiologicalCongress B-1040 B RUXELLES,BELGIUM (UKRC) T: +32/2/ 286 85 00 F: +32/2/ 286 85 08 27-29BritishNuclear Medicine Society BIRMINGHAM,UK WWW. IMAGINGMANAGEMENT. ORG (BNMS) www.ukrc.org.uk Spring Meeting 2006 PUBLISHER MANCHESTER, UK 24-27 GermanRadiology Congress C HRISTIAN M AROLT C . M @ IMAGINGMANAGEMENT. ORG www.bnms.org.uk BERLIN,GERMANY www.roentgenkongress.de MANAGING EDITOR D ERVLA S AINS JUNE 2006 EDITORIAL@ IMAGINGMANAGEMENT. ORG EDITORS th 14-1715 WorldCongress in Cardiac H ELICIA H ERMAN Electrophysiology andCardiac EUROPE @ EMCEUROPE . COM Techniques(CARDIOSTIM) AUGUST2006 S ONYA P LANITZER EUROPE @ EMCEUROPE . COM NICE, FRANCE 31-2 Congress of the European E DWARD S USMAN www.cardiostim.fr EDWARDSUSMAN@ CS. COM Association of Hospital R ORY W ATSON 19-23 EuropeanSociety of Managers RORYWATSON@ SKYNET. BE Gastrointestinaland 21st in Bi-annual Congress COMMUNICATIONS AbdominalRadiology Annual S VEN O EZEL Meeting (ESGAR) DUBLIN,IRELAND MEDIA@ IMAGINGMANAGEMENT. ORG www.eahm2006.ie CRETE, GREECE ARTDIRECTOR www.esgar.org S ARAH D AELEMAN LAYOUT. G 5@ EMCEUROPE . COM

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