Investing in Interventional Imaging >> Prof

T HE O FFICIAL V OICE OF THE E UROPEAN I MAGING I NITIATIVE

V OLUME 6ISSUE 4 S EPTEMBER -OCTOBER 2006 ISSN=1377-7629

RADIOLOGY ■ CARDIOLOGY ■ INTERVENTION ■ SURGERY ■ IT MANAGEMENT ■ EUROPE ■ ECONOMY ■ TRENDS ■ TECHNOLOGY

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THE FUTURE OF INTERVENTIONAL IMAGING

www.imagingmanagement.org

Content

3 Editorial 11 EU News

4 Association News 15 Industry News EDITOR-IN-CHIEF Prof. Iain McCall (UK)

EDITORIAL BOARD Prof. Hans Blickman (The Netherlands) COVER STORY: INTERVENTIONAL RADIOLOGY Prof. Georg Bongartz (Switzerland) Prof. Nevra Elmas (Turkey) 18 Investing in Interventional Imaging >> Prof. Thomas Vogl, Dr. Mohamed Nabil Prof. Guy Frija (France) Prof. Paolo Inchingolo (Italy) 22 Organisational Aspects of an Active IR Group Prof. Lars Lonn (Sweden) >> Hervé Rousseau, Francis Joffre, Octavio Cosin Prof. Heinz U. Lemke (Germany) 24 Clinical Care in Interventional Radiology Prof. Jarl A. Jakobsen (Norway) >> Prof. Jose Ignacio Bilbao Prof. Mieczyslaw Pasowicz (Poland) 26 Leading Interventional Radiology Across Europe Prof. Udo Sechtem (Germany) >> Interview with Prof. Johannes Lammer Prof. Rainer Seibel (Germany) Dr Nicola H. Strickland (UK) Prof. Henrik S. Thomsen (Denmark) FEATURES Prof. Vlastimil Valek (Czech Republic) Prof Berthold Wein (Germany) 30 Increasing Operational Effectiveness >> Prof. J. L. Bloem CORRESPONDENTS 31 Live 3D Echo Brings Real-time Benefits Prof. Frank Boudghene (France) in Paediatric Cardiac Care Prof. Davide Caramella (Italy) >> Prof. Ivan Salgo Nicole Denjoy (France) 34 Power Injectors in Computed Tomography Johan De Sutter (Belgium) >> Frank Ellwood, Dr. Nathan Manghat Prof. Adam Mester (Hungary) Sergei Nazarenko (Estonia) Dr. Hanna Pohjonen (Finland) 36 ECRI Healthcare Product Comparison Chart

GUEST AUTHORS Dr. Istvan Battyani (Hungary) Prof. Jose Ignacio Bilbao (Spain) Prof. J.L. Bloem (The Netherlands) COUNTRY FOCUS: IMAGING IN HUNGARY Prof. Octavio Cosin (France) 39 Overview of Healthcare in Hungary Prof. Frank Ellwood (UK) >> Dr. Ivan Golub Dr. Ivan Golub (Hungary) 42 Dealing With Organisational Conflicts Prof. Francis Joffre (France) >> Prof. Dr. András Palko Prof. johannes lammer (Austria) 43 Management Issues in a National Reasearch Programme Dr. nathan manghat (UK) >> Prof. István Battyáni Dr. Mohamed Nabil (Germany) Prof. Andras Palko (Hungary) 44 Developing the Science of Radiology in Hungary >> Dr. Gyongyi Nagy Prof. Gyongi Nagy (Hungary) Prof. Herve Rousseau (France) Dr Ivan Salgo (USA) Prof. Thomas Vogl (Germany) HOW TO... MY OPINION

46 How to Assess a Bid 47 Interview >> Prof. Hans Blickman >> Prof. Georg Bongartz The European Imaging Initiative (EII) is an informal network of related associa- tions, professionals and leading 48 Key Seminars & Conferences European stakeholders concerned with good management practices in the imaging industry.

Editorial

EditorialThe Future of Interventional Radiology The term ‘Interventional Radiology’ represents diagnostic and therapeutic procedures that are minimally invasive and PROF. IAIN MCCALL guided by an imaging method be it fluoroscopy, ultrasound, EDITOR-IN-CHIEF CT or MRI. These procedures, developed over many years by [email protected] radiologists, have become core components of the services offered by radiology departments and an essential part of management of many disorders. The success of these techniques has required many adaptations in the way patients are treated and the roles and responsibilities of the clinicians involved. There is increasing strain on radiology departments due to insufficient radiologists and an inadequate allocation of financial resources for consumables and staff time necessary for treating often complex conditions. While this is recognised by radiologists it is not always appreciated by managers and rarely by purchasers. In order to change this situation a number of points need to be addressed.

It must be recognised that radiologists are responsible for the care of the patient while they are providing treatment in the same manner as any other clinician and this must be recognised in their job plan and the facilities available to them. They need outpatient facilities to review patients prior to treatment and for follow-up and they also require access to beds which may be in day care facilities or for longer term treatment. The patients may be the sole clinical responsibility of the radiologist or in conjunction with other clinicians and radiologists must have sufficient clinical training and knowledge to manage those cases for which they are taking responsibility.

The radiologist involved in interventional procedures must be given the appropriate time in their work plan to undertake the clinical part of their work and the recording of work undertaken by radiology departments must be weighted accordingly to reflect this. A major reallocation of funding must also be made to radiology, which is often disadvantaged by payment systems.

It is often the case that the same procedure undertaken by a radiologist and a non-radiological clinician receive widely differing payments, as within radiology they are classed as a test compared to a full clinical episode in other hospital departments for exactly the same process. The DRG system covers the whole clinical episode and is usually allocated to the clinical department not to radiology which receives considerably less than is commensurate for the work undertaken. When interventional radiology techniques become the main therapeutic modality for a clinical condition the resource allocations are often not transferred and the original clinical area reduced to allow for the change in the treatment algorithm.

It is therefore essential that radiologists undertaking interventional procedures and minimally invasive treatments are enabled to perform these tasks safely and with adequate resources. This edition of the journal focuses on a number of these areas and should increase the understanding of radiology and hospital managers and also purchasers of the requirements of a successful interventional radiology service.

Prof. Iain McCall

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 3 AssociationAssociation News News

Hungary have long been affiliated with and present at MIR meetings Annual ‘Management since it was first initiated. This clearly demon- in Radiology’ (MIR) strates our support and belief in the essential role this annual meeting plays in Congress underpinning proper management practices.

The great advantages of organising such a meeting in one of Join Europe’s Most Prominent Experts, the “freshmen” countries of the EU, are twofold: on the one October 5 – 7 2006 hand it brings cutting-edge, hot topics of radiological management closer to the specialists of these countries; and on the other hand it provides an opportunity for members of the MIR community to collect first-hand experiences from an Dear colleagues and environment differing in many aspects from their own tradi- friends, tions. The synergism of these two factors may result in better understanding of this rapidly developing region and more On behalf of the extensive involvement of experts from these countries in the Local Organising activities of MIR. Committee, it gives me great Expert Scientific and Educational Programme pleasure to Thanks to the invaluable contributions of many experts from invite you to all over Europe, the scientific and educational programme of attend the 9th this year’s meeting promises to be both intellectually edition of provocative, and at the same time very useful from practical ‘Management in points of view, both for radiology and management special- Radiology’ (MIR) 2006 ists. Alongside a constructive and current programme, the Congress in Budapest. planned social events give you at least a small sample of the This unique platform, initiated taste and feeling of Budapest and Hungary. We kindly to address significant managerial issues that affect encourage you to take the opportunity to get acquainted the imaging industry from a scientific point of view, with the great historical monuments and exciting 21st century offers a wealth of opportunities to exchange expe- developments of this city. rience, introduce new tools and concepts and draw together a wide range of leading professionals, both speakers and delegates. Once again we look forward to meeting delegates, both old and new, and to welcoming you to the banks of the Danube for a successful and hopefully memorable scientific event. An Auspicious Background Although this marks the first occasion on which the annual MIR meeting will be held in Budapest, our beautiful and hos- Prof. Dr. András Palkó pitable capital city, representatives of the field of imaging in President of the Local Organizing Committee of MIR 2006

4 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES tional city centre on the plains of Pest, and its famous Welcome to bridges.

Budapest is also famous for its historical heritage, architec- Budapest tural grandeur, art collections and thermal spas. The city mer- its international attention this year, as it commemorates the Cultural and Historic Attractions 50th anniversary of the heroic struggle against the Red Army and Soviet colonisation. Dear colleagues,

Cultural Attractions It is with great pleasure that I cordially invite you to The Hungarian State Opera was Budapest to participate in the 9th Annual Meeting of built between 1875 and 1884 in ‘Management in Radiology’ (MIR). Over the past nine Italian neo-renaissance style. The editions, MIR has developed into a unique, pan- balcony on the façade has European initiative designed specifically to support best balustrade railings, with an practice in management in the imaging industry. I am arcaded driveway underneath. In the niches on both sides of delighted to introduce to those of you who have not yet the driveway stand the statues of Francis Liszt, the most experienced it, the many attractions of this year’s loca- famous Hungarian composer of the nineteenth century, and tion. of Francis Erkel, creator of Hungarian National Opera and the first director of this Opera House. The statues on the corner Budapest - Your Destination projections, between the Corinthian half-columns, represent Terpsichore, Erato, Thalia and Melpomene, the muses of This year’s venue for the MIR Meeting is the well-appointed dance, romantic poetry, comedy and tragedy. Either on Hotel Sofitel****, located centrally on the river side of the Thursday, October 5th or on Saturday, October 7th you will Danube, opposite the Royal Castle in Budapest. have the opportunity to enjoy Mozart’s ‘Don Giovanni’.

I have no doubt that delegates will experience a scientific As you can see, Budapest’s cultural and historic grandeur and welcoming atmosphere in Budapest, with a wealth of mean that is not only a destination for all leading profes- opportunities to renew old acquaintances and establish new sionals in the imaging industry with an interest in the links. We look forward to receiving not only members of MIR, exchange of information and networking possibilities offered but also non-members from Europe and overseas as well as annually by the MIR meeting, but also a rich and diverse their guests and families. location in itself. We look forward to welcoming you to Budapest during the first week in October 2006. Why Come to Budapest? Budapest is the most beautiful city for me in the world, and such a historic and charming venue provides an ideal setting for this year’s MIR congress. Budapest is situated astride the Danube; the capital gives a glimpse of the diversity of Hungary from the pleasant green of the hills of Buda to the wide flat plain of Pest. Its numerous attractions include the Royal Palace on the Castle Hill, the waterfronts of the majes- Adam Mester M.D., Ph.D. tic Danube, the flowered haven of Margaret Island, the tradi- Member of the Local Organising Committee

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 5 MIR 2006 ‘Current Trends and Future Priorities’ MIR 2006 Here we offer a sample of some of the leading speakers and topics to be included over this leading three-day PPROGRAMMEROGRAMME conference taking place from October 5 – 7, 2006, in Budapest, Hungary. For full programme details or to register online, please HHIGHLIGHTSIGHLIGHTS visit www.ewgmr.org.

Thursday, October 5

• The End of Radiology as an Independent Specialty: Managing Imaging of the Future Nicola Strickland

• Radiologic Communication: A Legal Duty, A Moral Imperative Leonard Berlin

• Managing Radiological Staff in a Regional Digital Imaging System Lluis Donoso Bach

• Demise of PACS as we knew it: The Next Generation with Streaming Digital Archiving Hanna Pohjonen

• Multilingual Structured Reporting across Borders Hans Blickman

• Image Management Solution for Multi Disciplinary Applications Peter Mildenberger

• New Approaches to Web Based Education in Radiology Harvey Neiman

• An Incentive System for Radiologists in an Academic Environment Edward I. Bluth Friday, October 6

• The National EPR and the Inclusion of Medical Imaging Michel Claudon

• CD-Rom for Image Exchange – The Quality Assurance Initiative of the German Roentgen Society (DRG) Peter Mildenberger

6 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES • Leadership Impact and Strategies Johan Bloem

• Maximising Efficiency in the Imaging Departments via Business Intelligence Reports and the Equipment Utilization Reports Jan Schillebeeckx

• How Radiology Practises can Increase their Productivity - Findings from an Empirical Study Jonathan Sunshine

• How to Manage Research in an Academic Department of Radiology Gabriel P. Krestin

• Radiology: The Viewpoint of the University’s Vice-President for Research Mathias Langer - Elmar Kotter Saturday, October 7

• Teambuilding from Communication to Cooperation Gerhard Pohl

• Mergers of Radiology Departments Pablo Ros

• Development and Experience with a Computer Aided Quality-Management System G. Pache – Elmar Kotter

• Performance Indicators in Radiology Silvia Ondategui-Parra

REGISTRATION FORM Please return this form to: MIR Office, Antonio Santoro Fax: +39 06 50 934 250 (please dial 0 before 6) or e-mail to: [email protected]

(Please write in capital letters)

Dr. K Prof. K Mr. K Ms. K FAMILY NAME FIRST NAME INSTITUTION ADDRESS ZIP CODE CITY COUNTRY TEL: FAX: E-MAIL: @ Specialty: Radiologist K Informatics K Other K

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 7 AssociationAssociation News News

24th International Congress

New IHE Member in Israel The recently held 24th International IHE Europe welcomes new member IHE The programme offered almost a hun- EuroPACS Conference, which took place Israel (www.ihe-il.org), which was offi- dred different scientific lectures, work- June 14 - 17 2006 in Trondheim, Norway, cially initiated on 17 May 2006, in the shops and meetings and focused on the addressed a wide range of information presence of Mr. Charles Parisot, Vendor latest and most significant develop- technologies and related topics, over the Co-Chair of IHE-IT Infrastructure. IHE ments in clinical practice, research and three days of this leading European con- Israel currently counts more than fifty education within digital radiology. Roald ference. With cutting-edge topics rang- registered members and is part of the Bergstrom, President of the 24th ing from Image Processing and CAD, to IHE Europe initiative. The User Co-Chair EuroPACS Conference, and Jacob Hygen, Broadband and PACS, and Security is Ziv Rosenbaum and the Vendor Co- Managing Director KITH, would like to Issues, the conference proved once Chair is Roni Zaharia. thank all speakers and registrants for again that it is the central gathering participating in the success of this Next Events point for specialists in medical imaging, event. digital x-ray, PACS and digital systems The IHE Europe Cardiology Integration for eHealth. Profiles will be demonstrated at the www.europacs.org World Congress of Cardiology in Barcelona (2-6 September). IHE-Europe will also be present at The World of Health IT 2006 Conference & Exhibition, 10-13 October in Geneva. www.ihe-europe.org

Graduate School of Medicine) and and Virtual Endoscopy • Kiyonari Inamura, PhD (Professor of Image Processing and Display • Kansai University of International Hospital-wide PACS and Studies) under the auspices of the Japan Telemedicine • Institutes of Computer Assisted Computer Applications for e.g. Radiology and Surgery and the Science Neurosurgery, Head and Neck, Results Announced Council of Japan. Orthopaedics, Ear Nose and Throat, From CARS 2006 etc. • A broad spectrum of medical and tech- Image Guided Therapy The 20th International Congress and • Surgical Robotics and Exhibition of CARS 2006 (Computer nological disciplines was represented at CARS 2006 with tutorials, special pre- Instrumentation Assisted Radiology and Surgery) was • sentations and scientific papers and Surgical Navigation and successfully held at the Osaka Simulation International Convention Centre in posters covering topics on information technologies in radiology and surgery Osaka, Japan with 855 congress regis- www.cars-int.org trants from 43 countries. The meeting for clinical application fields, including: • was organised by Hironabu Nakamura Medical Imaging, e.g. CT, MR, US, MD, PhD (Professor of Osaka University SPECT, PET, DR, Molecular Imaging,

8 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES

AssociationAssociation News News

systems marketed by GE, Siemens, and Toshiba. The systems are rated for two different uses: inpatient imaging (performed in hospitals) and outpatient imaging (most often performed in imag- ria, extensive product specifications, and ing centres). Additionally, the systems detailed results and analysis from ECRI’s are evaluated and rated according to ECRI Offers Selection and testing to assist healthcare organisa- their ability to meet the needs of three Purchasing Recommendations tions in selecting and purchasing an MR specialised applications - breast and car- Choosing the right MR system involves system. diac imaging and functional MR imaging. careful planning and selecting of bene- In this issue, ECRI found key differentia- fits and features that meet the needs of ECRI offers guidance on options to con- tors between models: each of the three healthcare facilities. ECRI recently pub- sider during the selection process, such models received a preferred rating in at lished an evaluation of three 1.5-tesla as different field strengths, gradient sys- least one specific category of use. MR systems. The in-depth article pub- tems, coils, channels, and specialised lished in ECRI’s Health Devices journal imaging features. In addition, ECRI www.ecri.org.uk provides information on selection crite- details offerings of three 1.5-tesla MR

ESMRMB 2006 – Congress Details Prof. John Griffiths, speaking about Announced "Cancer Metabolism - From the Molecule to the Patient". Besides planning the meeting contents, the SPC has also The 23rd Annual Scientific Meeting of the Scientific Programme reviewed the meeting format, seeking ways of adjusting it to changing needs ESMRMB will take place in Warsaw, The Scientific Programme Committee and expectations. Poland, from 21 – 23 September, 2006. (SPC) chaired by Professor Klaas As a result, two attractive format modifi- The course venue is the Gromada Prüssmann has prepared a well-bal- cations have been introduced. The meet- Conference Centre in Warsaw. anced and exciting programme. The pro- ing's educational profile has been gramme will cover Teaching Sessions, enhanced by extending the traditional The ESMRMB is a multidisciplinary socie- Plenary Lectures, Mini-Categorical teaching programme across the whole ty dedicated to the development and Courses, Debates, Discussions and conference. This change is intended to application of magnetic resonance tech- Scientific Sessions with the highest pos- increase flexibility in tailoring your per- niques in medicine and biology. Its annu- sible scientific quality. The aim is to give sonal itinerary, whether you are a basic al meetings aim to provide a stimulating a multidisciplinary perspective on the scientist or a clinician, fairly new to MR platform where clinical and basic hottest and most recent topics in our or a seasoned expert. Also, the schedule researchers meet, share their latest find- scientific field. The collaboration with has been slightly condensed to form a ings and discuss new ideas. our Polish colleagues will be under- compact meeting of three days; scored with a back-to-back meeting of Thursday morning to Saturday night. The Warsaw is a quite obvious choice for the the Polish MR Society on Wednesday. venue of this scientific meeting: it is an overall number of sessions has been preserved, so this change comes at no exciting, truly European capital. An Committed to ESMRMB traditions, the expense to programme scope or diversi- impressively large and active MR commu- scientific programme of 2006 combines ty, instead offering more session choices nity is present in the country and last but ample space for current research with than previously. not least members of the Local topical overview lectures and advanced Organising Committee have been found- MR education. This year's Sir Peter www.esmrmb.org ing and active members of our Society. Mansfield Lecture will be delivered by

10 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES EU News

EUROPEAN COURT OF AUDITORS Monitoring EU Funds

The European Court of Auditors is the external audit institution of the European Union and acts as its “financial conscience”. Founded in 1977 in Luxembourg, it is independent from other European Union (EU) institutions. Its task is to keep track of EU funds, making sure that the Commission manages it properly. Based on their Annual Report, the European Parliament gives the Commission final discharge ILZE RAATH for the execution of every annual budget. EDITOR EUROPEAN AFFAIRS [email protected]

Established on 22 July 1975 by the organisation handling EU income or financial year. The content of this Treaty of Brussels, the Court started expenditure. Any irregularities are report plays an important role in the operating as an external Community reported to the European Parliament Parliament’s decision whether or not audit body in October 1977. Since and Council. The Court’s audit to approve the Commission’s han- the signing of the Treaty of responsibilities have been extended dling of the budget. If approved, the Maastricht, the Court has been recog- to Community funds managed by Court sends the Council and the nised as one of the five institutions outside bodies and by the European Parliament a statement of assurance of the European Communities. Investment Bank. that European taxpayers’ money was judiciously spent. Before the Main Role European Union’s financial regula- Their findings are published in vari- The Court independently audits the tions are adopted, the Court gives ous reports, which draw the attention collection and spending of European their opinion. They may comment at of the Commission and the member Union funds by the institutions, any time on specific issues or give an states to any problems. These publi- European development funds and opinion at the request of an EU insti- cations are: other EU agencies and bodies. • tution. Furthermore, they investigate the Annual Report on the whether financial operations have implementation of the European Court Officials been properly recorded, legally and Union budget for each financial • Members regularly executed and managed to year; According to the EC Treaty, the Court • ensure efficiency and transparency. opinions; consists of one Member from every • The Court's role, as external auditor, specific annual reports on Member State. These Members are is to assess the financial manage- European Union bodies; and, appointed by the Council, after con- • ment of the budget as a whole. special reports on subjects of sultation with the European particular interest. Parliament based on nominations by What Does This Mean in One of its most important functions every Member State. Members of the Practice? is to assist the budgetary authority Court are chosen on the basis of hav- In practice, this means that the Court (European Parliament and Council) by ing worked for an auditing institution examines the paperwork of any issuing a report on the previous in their country of origin or their spe-

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 11 EU News

cific qualifications. They work full- supreme audit institutions of the body with its Members adopting time for the Court. Their term of Member and beneficiary States. audit reports and opinions by major- office is six years and can be ity vote. Meetings are not open to renewed. • Secretary-General the public. The Court draws up its The Secretary-General, the most sen- own rules of procedure governing its The Members sit as a college that is ior official in the institution, is internal operation, which are then the main decision-making body of appointed by the Court. His/her submitted to the Council for the Court. The annual work pro- duties include managing the Court’s approval. gramme sets out the tasks that every staff and administration, such as pro- Member is responsible for imple- fessional training and translation The auditors are divided into audit menting. Specialised audit staff services (a unit for every official lan- groups that are sub-divided into var- assists them. guage) as well as the Court’s secre- ious specialised units, which cover tariat. the different areas of the budget. The For the sake of efficiency, “chambers” CEAD audit group (Coordination, (with a limited number of members • Human Resources Evaluation, Assurance and each) can be set up to adopt certain The entire staff comprises about 760 Development) is responsible for the types of reports or opinions. auditors, translators and administra- coordination of the Statement of tive support. The Court employs Assurance, quality assurance and the • President nationals from all the Member States development of the Court's audit A President whom the Members elect to ensure a balanced spread of lin- methodology. The Court assigns each from amongst their number heads guistic and professional skills. Staff Member to a group, which is chaired the Court. The President’s term of comes from a wide range of back- by a “Dean”. Members of the group office is three years and is renew- grounds, from both the public and elect the Dean from amongst their able. His/her role is that of ‘primus private sectors e.g. accountancy prac- number for a renewable two-year inter pares’, or ‘first amongst equals’. tice, internal and external audit, law term. The Dean’s role is to ensure the S/he has to chair Court meetings and and economics, etc. The recruitment smooth running of the group and its ensure that decisions are implement- policy follows the general principles divisions in agreement with all the ed and all the institution’s activities and employment conditions of the Members of that group. are properly carried out. EU institutions, and its workforce comprises both permanent civil ser- Administrative Committee Furthermore, the President is respon- vants and staff on temporary con- The Administrative Committee, com- sible for the legal service and the tracts. posed of Members representing the external relations department, audit groups, takes care of adminis- regarding the discharge authority, Internal Organisation trative matters requiring a formal other EU institutions and the The Court operates as a collegiate decision by the Court. Since 2004,

12 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES EU News

the Court may adopt documents Union, the European Development Under the Treaty, the Court has right without discussion based on a two- Funds and of all other bodies and of access to any information it thirds decision of the Members of an agencies set up by the Union; and, requires to carry out its tasks. The audit group or the Administrative • selected audit tasks. The Court auditors do on-the-spot checks at the Committee. The Court also appoints selects budgetary areas or manage- various EU institutions, at the prem- an Internal Auditor who reports to ment topics of specific interest for ises of bodies or legal persons man- the Audit Committee (comprised of detailed audit. aging funds on behalf of the Union, three Members of the Court and an including all levels of administration external expert). The Court works independently of dealing with EU funds. national governments and other EU The Court is financed from the gener- institutions. They are free to decide al budget of the European Union, on topics, what they want to audit The European Anti- which the European Parliament and when they want to present their Fraud Office (OLAF) adopts after consultation with the observations and publicise findings. Council. The budget amounted to Every year the Court reports on the about € 95 million in 2004, repre- Selecting Topics and management of the budget, any senting 0.1 % of the total expendi- Identifying Tasks irregularities and suspected fraud. ture of the European Union and 1.6 % The Court selects a number of budg- of the total administrative expendi- etary and management topics every The European Commission and the ture of the EU institutions and bodies. year, but does not audit every budg- Member States are primarily respon- etary area in depth every year. sible for preventing, detecting and At the Court’s behest, an external audit firm audits its financial state- As a basis for identifying audit tasks, investigating errors and irregularities. the Court regularly undertakes a risk ments. These results are then com- The Court’s task is to assess how municated to the European analysis of the entire audit field con- Parliament and the Council. The sidering issues such as known prob- well they have fulfilled their duty, and financial statements and accompany- lems or weaknesses, financial signifi- then suggests improvements. ing audit report are published in the cance and findings of previous When fraud, corruption or any illegal Official Journal and on the Court's audits. The Court ranks these poten- website. tial tasks by priority based on the activity is identified, the matter is results of the risk analysis and the communicated to the European Anti- Audit Scope need to ensure a balanced coverage Fraud Office (OLAF). The Office was The Treaty requires the Court to audit of budgetary area. In addition, specif- the implementation of the general ic concerns of the European given responsibility for conducting budget of the European Union, the Parliament, the Council and the pub- detailed administrative anti-fraud European Development Funds as well lic at large are also considered before investigations, instigating prosecu- as the financial statements of EU the final selection of audit tasks is bodies and agencies. The scope of made. tions in Member and beneficiary audits ranges from financial state- States, and recovering EU funds. A ments to detailed examinations of The Court’s audit policies are largely specific budgetary areas or manage- based on INTOSAI Auditing Standards special independent status was con- ment topics. These audit tasks are and International Standards on ferred upon the Office. divided into: Auditing – issued by the International • recurrent audit tasks, which have Federation of Accountants – that to done every year such as the have been adapted to suit the financial statements of the European European Union context.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 13 EU News

How is an Audit Carried Out? • Reporting day administration, management and Every audit is carried out in three Audit reports communicate the results control of EU funds are undertaken at main stages: planning, testing and of the Court's work to the auditee, national and regional levels, resulting reporting. the discharge authority and the gen- in more transparent decision-making eral public. After completion of the to the citizen. • Planning audit work, the auditors draw up a The Court’s work programme is draft audit report ("the Court's pre- Both political scrutiny and close planned on a multi-annual and annu- liminary observations") which con- media attention – especially to cases al basis. The multi-annual plan tain: of fraud or misuse – necessitate the entails defining and updating its • audit observations and findings; European Court of Auditors’ role as strategy, whereas the annual plan • conclusions on the audit external auditor of the European details specific tasks for that year. objectives; and, Union. The auditors prepare an audit-plan- • recommendations ning memorandum for every audit for improvement. The Court’s Vital Role undertaken. This memorandum sets Although not infallible, the Court out the audit scope, approach and The draft audit report is examined strives to uphold its mandate by pro- audit objectives, and how these are first by the audit group and then sub- viding the best possible service in an to be achieved in the most efficient mitted for approval by the Court. It is expanding European Union. The and cost-effective way. The planning then sent to the auditee (European Court achieves this; • memorandum is complemented by Commission or other European Union by publishing its reports the an audit programme that sets out the institution concerned) in the context Court helps promote trans audit testing needed in detail. The of a bilateral discussion procedure. parency and accountability in audit planning memoranda and audit The auditee checks the report and the management of European programmes are submitted for sends an official reply – taking into Union funds; • approval to the audit group responsi- account the reactions of the Member through its audit work the ble for that task. States – to the Court. The Court either Court helps ensure that EU maintains its original observations or funds are collected and used • Testing changes them to correct any errors or in accordance with the appli Testing is done to obtain sufficient, ambiguities, depending on the reply. cable rules and regulations; • relevant and reliable audit evidence Finally, the auditee's reply is pub- its audit observations and re that will allow the auditors to reach lished with the audit report. At the commendations help managers conclusions on the audit objectives. end of the bilateral discussion proce- of EU funds improve their per Teams of two or three collect evi- dure, the Court formally adopts the formance and contribute dence in accordance with the audit definitive audit report. towards improving sound programme within European Union financial management; and, institutions and in Member and ben- Benefits for the EU citizen • its audit reports serve as a eficiary States. Methods include As the Court of Auditors is the finan- basis for the democratic examining and testing systems and cial conscience of the European scrutiny of the utilisation of transactions by applying various Union, it stands to reason that citi- EU funds by the European techniques, e.g. statistical sampling. zens expect to see and reap the ben- Parliament and the Council. In some cases, external experts are efits of its existence. In practice, both engaged to provide specialist knowl- the Commission and, for over 80% of edge. Audit evidence can be obtained EU expenditure, multiple administra- in various ways: examining key sup- tive layers in Member and beneficiary porting documentation, physical States are responsible for managing inspection or enquiry. EU programmes. Increasingly, day-to-

14 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Industry News

• Matrox Display Controller Boards RoHS-compliant The European Parliament and the Toronto East Network (TEN) as • Agfa HealthCare Preferred Vendor for Major PACS Project Council of the European Union the preferred vendor for the

• Philips Acquire Witt adopted a Directive on the region’s PACS project. Requiring Biomedical Corporation restriction of the use of certain the integration of several RIS • Kodak Applies for FDA Approval hazardous substances in electri- and PACS systems from different for CR Mammography cal and electronic equipment, vendors, this project will utilise • Barco Wins Frost & Sullivan Award for 3D Imaging Software known as the RoHS Directive. Agfa’s IMPAX solution.

• Planmed Applies to FDA for Full This Directive will restrict place- Field Digital Mammography ment on the EU market of electri- System The TEN PACS Project is a joint cal and electronic equipment initiative commissioned by a vol- • Siemens Completes Acquisition of Diagnostic Products Corporation containing lead, mercury, cadmi- untary consortium of 16 hospital • NEC Develops Design Method um, hexavalent chromium, PBB, corporations. In cooperation with for Large Scale & High Speed LSI and PBDE as of July 1st, 2006. these hospitals and Canada • Inauguration of Sectra's New Office in the Netherlands Health Infoway, the TEN PACS Matrox RoHS-compliant medical Project Management Office has display controller boards are defined a three year phased form, fit and function equivalent implementation strategy for the to their non-RoHS-compliant creation of a shared Diagnostic counterparts, and are drop-in Imaging Repository for images compatible. Existing Matrox soft- and reports. ware, drivers and graphic BIOS operate transparently with the Agfa HealthCare will provide its RoHS-compliant versions. IMPAX solution for current non- Matrox Display Controller PACS sites in the TEN and for the Boards RoHS-compliant implementation of a regional Matrox Graphics Inc. display Diagnostic Imaging Repository. controller boards, including The Repository will allow all par- the Matrox MED Series, ticipating hospital corporations RAD Series, TheatreVUE Series Agfa HealthCare Preferred to centrally store image and and AuroraVX Series have Vendor for Major PACS report data, and to access rele- been shipping as RoHS-compli- Project vant prior patient images, ant boards over the last few Agfa HealthCare announced that regardless of which TEN site months. it has been selected by the acquired them.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 15 Industry News

METRIX was approved for quanti- tative vessel analysis of CT and MR angiographic studies; VOXAR COLONSCREEN was approved for reading CT colonography studies Kodak Applies for Barco Wins Frost & Sullivan of symptomatic and asympto- FDA Approval Award for 3D Imaging for CR Mammography matic patients. These FDA Software approved clinical application Kodak has applied to the U.S. Frost & Sullivan has awarded modules add greater value to the Food and Drug Administration Barco with the Customer Value VOXAR 3D product line by pro- (FDA) for approval of its CR sys- Award for VOXAR 3D, a portfolio viding dedicated, clinical-focused tem for mammography and the of advanced visualisation soft- tools for specific imaging appli- company is currently conducting ware and clinical applications. cations. clinical trials at several sites in According to Frost & Sullivan, the U.S. and Canada. The mam- Barco's VOXAR 3D software pro- mography feature captures mam- vides customers with the best mography and general radiogra- value for their investment in an phy exams with the same com- advanced visualisation solution puted radiography (CR) platform. for a PACS environment. Capturing mammography images Planmed Applies to FDA for requires the use of specialised Frost & Sullivan granted the Full Field Digital KODAK mammography cassettes award to Barco because of Mammography System and screens. VOXAR 3D's cost-effective Planmed has recently submitted deployment options, which pro- a premarket approval (PMA) Kodak currently offers a broad vide unlimited access to application to the Food and Drug portfolio of mammography solu- advanced visualisation toolsets Administration (FDA) for the tions including CAD for mam- and clinical application modules company’s Planmed Nuance* Full mography; PACS that includes a everywhere users need them Field Digital Mammography KODAK CARESTREAM Mammo- throughout the hospital. System. Planmed hopes to graphy Workstation offering spe- receive the application approval cial display protocols and tools In addition, Barco received the before the end of the year. designed to enhance radiolo- Award because it has extended gists’ productivity; and a laser the value of its VOXAR 3D soft- The Planmed Nuance is based on imaging system with special software with the introduction of amorphous selenium (a-Se) ware for printing digital mam- specific clinical applications. In detector technology. Planmed mography images. 2005, Barco received FDA 510(k) plans to offer two detector sizes. clearance from the U.S. Food and Customers may choose either the Drug Administration for two inno- 17 cm x 23.9 cm Bucky or the vative additions to the VOXAR 3D optional 23.9 cm x 30.5 cm product line. VOXAR 3D VESSEL- Bucky which will accommodate

16 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Industry News

diac disease, as well as hormone LSI to 1/3 of the conventional most patients. The Nuance unit and allergy conditions.Matrox design method. will also be equipped with the RoHS-compliant medical display integrated MaxView Breast controller boards are form, fit Positioning device, which pro- and function equivalent to their vides more chest wall tissue on non-RoHS-compliant counter- imaging exams. parts, and are drop-in compatible. Existing Matrox software, drivers and graphic BIOS operate Inauguration of Sectra's transparently with the RoHS- New Office in the compliant versions. Netherlands Sectra Communications Dutch Siemens Completes branch office was recently inau- Acquisition of Diagnostic gurated in the Hague, the Products Corporation Netherlands. The inauguration Siemens has completed its was held in presence of around acquisition of Diagnostic twenty invited customers, among NEC Develops Design Products Corporation (DPC), these representatives from the marking a significant milestone Method for Large Scale & Dutch Ministry of Interior, the for Siemens as it enters the in- High Speed LSI Dutch Ministry of Foreign Affairs, vitro diagnostics (IVD) market. NEC Corporation (NEC) and NEC the International Crime Court and Together with DPC, Siemens Electronics Corporation (NEC Eurojust. Medical Solutions will become Electronics) announced that they Sectra's Country Manager in the the first full service diagnostics have succeeded in the develop- Netherlands, Jeroen de Muijnck, company. Yesterday, DPC share- ment of a new design method for hosted the inauguration at holders approved the merger of large-scale integrations (LSIs) Sectra's local office in the Zürich DPC into a wholly owned sub- with more than 50 million tran- Tower in central Hague. The sidiary of Siemens Medical sistors, operating at a speed of office is well-placed in the city Solutions, Inc. In the merger several hundred megahertz. NEC centre, near Sectra's customers each share of DPC common stock and NEC Electronics’ new design within the various ministries in was converted into the right to method introduces a “Border the Netherlands. receive a cash payment of Moving Method” into the design Sectra's CEO, Dr Jan-Olof Brüer $58.50 per share. Founded in process, which completely elimi- held a welcoming speech, 1971, DPC is a global leader in nates the need for the budgeting addressing the need for secure immunodiagnostics, focusing on process and re-designing of hier- interoperability within European developing, manufacturing, and archical blocks, dramatically countries as international threats distributing automated body shortening the total length of to communications are nowadays fluid analysers and tests, such as time required for backend design viewed on a global, rather than those related to cancer and car- for large scale and high speed national territorial perspective.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 17 Cover Story Interventional Radiology

INVESTING IN INTERVENTIONAL IMAGING

Which Technology is Worthwhile?

plasty and stenting of stenosed or occluded arteries, thrombus aspiration and local throm- bolytic therapy. More recent revascularisation techniques are laser angioplasty, cryoplasty, and brachytherapy.

Applications of Interventional Imaging Interventional tumour management is a broad field which involves various techniques based on different physical and medical principles. Regional transarterial chemotherapy of malignant New Techniques in Interventional Imaging tumours is another category that can be com- Interventional radiology is one of the youngest, bined with embolisation or performed solely as fastest-growing specialties in medicine. The tech- chemoperfusion. Tumour biopsy and thermal nology of diagnostic imaging is progressing at an ablation can be guided by X-ray fluoroscopy, equally rapid rate as the development of new ultrasound, conventional CT, CT fluoroscopy and techniques of intervention based on new instru- open/closed MRI. Radiofrequency waves, laser, ments and material but, above all, on the creativ- microwave, and galvanotherapy (direct electric ity of the human mind. The domain of interven- current) are all used as mechanisms of ablation tional radiology includes almost all body sys- through extreme heating, whereas cryoablation tems, as any area that can be imaged radiologi- depends on extreme cooling. Percutaneous alco- cally can also be treated under imaging guidance. hol injection and brachytherapy are other meth- AUTHORS The vascular system is the most prominent field ods of chemical or radiotherapy ablation. PROF. THOMAS J. VOGL of intervention which can be divided into thera- (above) peutic vaso-occlusion or embolisation and revas- Breakthroughs in spinal interventions include cularisation. vertebroplasty, disc prolapse aspiration, disc DR. MOHAMED NABIL chemonucleolysis and image-guided nerve block- Embolisation involves tumour feeding arteries, age for pain management. Under normal circum- INSTITUTE FOR DIAGNOSTIC AND INTERVENTIONAL bleeding arteries, aneurysms, arteriovenous mal- stances, these procedures can be performed on RADIOLOGY formations or fistulas. More recently venous an outpatient basis without the need for a long JOHANN WOLFGANG GOETHE- occlusion was introduced in several clinical situ- hospital stay with all its financial and manpower UNIVERSITY CLINIC ations such as varicocele, erectile dysfunction requirements. These techniques mentioned repre- FRANKFURT AM MAIN due to venous leakage, and lower limb varicose sent most but not the complete range of inter- GERMANY veins. Inferior vena cava (IVC) filters are a unique ventions available in practice or research. New [email protected] technique for protection against pulmonary techniques are being added to the list at an embolism without occlusion of the IVC. amazing pace. Revascularisation includes mainly balloon angio- Advances in Technology

18 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Cover Story Interventional Radiology TTT

Interventional imaging is dependent on imaging shortcoming but is sometimes an advantage for systems. We are privileged now to experience a certain types of examination. breathtaking rate of development in imaging equipments. Both CT and MRI are highly valuable Open low-field MRI units (0.2-1.5 Tesla) are used for image-guided interventions and vascular in many centres partially in diagnostic studies for imaging with regard to intervention planning. The claustrophobic patients or other patient-related development of multidetector row CT (MDCT) and reasons. However, in future they should play a CT fluoroscopy gave CT the chance to stay ahead bigger role in guided interventions, which would and maintain a key role in vascular and interven- be more valuable in the broader context. tional imaging. Interventions can be performed under CT fluoroscopy guidance in near real-time Although all percutaneous procedures, whether imaging. CT angiography is nowadays compara- biopsy, drainage or ablation, can be successfully ble to MR angiography and even to conventional performed under CT guidance, the superior soft- angiography with regard to sensitivity and speci- tissue contrast afforded by MRI makes it attrac- ficity and is a valuable, quick and minimally inva- tive to interventionalists for less risky access to sive screening technique in peripheral, visceral, coronary and cerebral arterial diseases.

However, this is only possible due to the multidetector row advantage, which allows faster imaging of the contrast medium bolus with minimal loss of information and hence superior spatial and temporal resolution and also more effi-

“New techniques are being added to the list at an amazing pace.” cient 3D reconstruction. The more the numbers of detector rows, the more these advantages are Figure 1: Open MRI unit showing the monitor pronounced. With the advent of 64-slice CT, inter- console (3) for near real-time viewing during ventions can sometimes be performed without the procedure. the need for CT fluoroscopy as the whole area under examination is covered by one scan in a fraction of a second. lesions and better monitoring of Benefits of MRI ablation. A small monitor console in the MRI MRI has also shown remarkable development room is more practical for near real-time surveil- with the production of machines up to 4 Tesla lance of the procedure. while 3 Tesla MRI is now widely supplied by Gems, Philips and Siemens for clinical applica- The necessity of using MR-compatible needles tions. The benefits of higher field strength are and applicators increases costs by approximately mainly an improved signal-to-noise ratio, hence 10 - 15% in comparison to a similar procedure diminished acquisition times and/or better spatial under CT guidance. MR-guided interventions can resolution at equivalent acquisition times and sometimes take a little longer than CT-guided improved patient comfort (shorter examination interventions. This is why open MRI could not time due to parallel acquisition, diminished noise replace CT for routine use in all interventions and level, and shorter magnets). An increase in the should be warranted only for selected cases magnetic susceptibility effects is an associated where other imaging techniques lack tissue con-

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 19

Cover Story Interventional Radiology TTT

trast or vascular conspicuity to provide safe Rapid exchange angioplasty catheters and bal- access. loon-expandable stents are much more practical than over-the-wire counterparts especially in Angiographic Devices sophisticated cerebral, renal or below-knee There are some angiographic devices which are angioplasty. They are much easier to use and can not always abundant in interventional units although the need for them is progressively growing. They deserve a large share in the budget of interventional imaging. Stent-grafts used “Interventional successfully nowadays in thoracic and abdominal Radiology is one of aortic and iliac aneurysms and dissections are an example. the fastest-growing

The use of limb extensions and fenestration has specialties” extended its applications to cases with iliac, renal and mesenteric involvement. Endovascular repair has proved to be a cost-effective alternative compared with open surgery for the elective be more accurately applied which increases the repair of abdominal aortic aneurysms.Another technical success. type of stent-graft is the covered stents which have a valuable role to play in the treatment of Conclusion large bleeding arteries that cannot be considered In conclusion, there are a myriad of ways in for embolisation. They are also used during tran- which interventional imaging is developing not sjugular intrahepatic porto-systemic shunts only in terms of the diseases in which it can treat (TIPSS) and percutaneous biliary drainage (PTD) but also the technology that is facilitating it, into to reduce the probability of endostent mucosal an exciting and forward-looking field for the pro- growth and narrowing. vision of better standards in healthcare.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 21 TTT Cover Story Interventional Radiology

ORGANISATIONAL ASPECTS OF AN ACTIVE IR GROUP Adapting the Environment for Optimal Healthcare

Interventional radiology is a continuously emerg- ised in an autonomous way to deal with the ing field, recognised today by the entire spectrum patient’s and radiologist’s needs. In this article, we will concentrate on the organisation of such of the medical community. Beyond political and specific structure; firstly, how to organise the strategic aspects of general radiological organisa- activity of IR in an isolated area, and secondly, why we need an isolated area. tion, the specific nature of interventional radiology strictly regulates how it must be organised Although interventional radiology is qualified as minimally invasive, its increasing complexity in within a department of radiology, both for the more and more fragile patients coupled with the quality of patient care and for optimal function of frequency of combined interventions, entail a the whole department. major infectious risk if they are not performed in optimal aseptic conditions. This risk must be minimised by appropriate adaptation of the phys- Routine Interventions ical environment and working practice. Moreover, When it comes to managing a daily IR practice, if working conditions are not acceptable, most two levels of activity can be distinguished. The combined interventions such as aortic stent first level relates to simple invasive acts, diag- grafts will be carried out in the surgical room. nostic or therapeutic, not requiring specific equipment, Finding the Best Location “Synergy within but at the same time, requir- What is the best location for an IR suite, from an ing the whole “radiological organisational perspective? There are several the department is armamentarium” for guid- options that can be proposed that vary according the key to success” ance. To name but a few, per- to the physical proximity between the depart- cutaneous guided biopsies, ment of radiology and the operating theatres, infiltrations of nervous roots, and also to the importance and the types of stereotaxic manage of breast lesions, etc. These interventional activities carried out. techniques use ultrasound (US) guidance, x-rays, CT and even MR and are carried out using current In my opinion, there are two options. The first is equipment of a department of radiology under to install an interventional suite inside or close strict rules of asepsis. They have the disadvan- to the surgical operating room in order to bene- tage of demanding longer machine occupation fit from access, circuits and the aseptic condi- times than diagnostic explorations, therefore tions of surgical suites. This solution implies a raising the question of whether equipment complete restructuring of the room to meet radi- should be exclusively dedicated to this type of ation protection requirements and to offer suffi- activity. cient space to install several modalities. However, the use of mobile equipment cannot Concerning MR, nowadays there are machines provide the same performance as angiography that allow easier access to the patient (open MR machines, and operating rooms are not designed AUTHORS or broad opening) as well as MR-compatible for the safe use of x-rays. The second option is

HERVÉ ROUSSEAU material, but again the much longer times of to create inside the radiology department, an iso- machine occupation for these acts, can constitute lated section that complies with all required radi- FRANCIS JOFFRE an obstacle to the development and use of MR- ological and surgical prerequisites. guided IR. OCTAVIO COSIN Why Have an Isolated Suite? Special Interventions The IR area must be physically autonomous and DEPARTMENT OF RADIOLOGY RANGUEIL HOSPITAL The second level is related to more demanding isolated from the rest of the department, but at TOULOUSE, FRANCE interventions, requiring a specific, dedicated and the same time, closely connected to other diag- [email protected] well-equipped structure, that should be organ- nostic radiology facilities. Total isolation allows

22 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Cover Story Interventional Radiology TTT

application of appropriate standards of asepsis Incorporating a CT scanner and angiography and hygiene: controlled access, organisation of equipment in the same area has been proposed, different and separate traffic (e.g., patient, staff, but in addition to the high cost, this configura- sterile and contaminated material), inside the tion requires extended space. section. All the rules of surgical hygiene must be applied. The advantage in terms of safety is obvi- The expansion of flat-panel technology in angiog- ous and the risk of nosocomial infection is raphy brings an attractive solution. Thanks to reduced. The interventional section has to rotational angiography, it is possible to obtain 3D become a “no-microbe area”. Permanent pres- reconstructions, as well as CT-like images whose ence of surgical and anaesthetic equipment is quality is sufficient for the majority of interven- required. tions requiring percutaneous guidance and/or immediate post-interventional checks. Access to External Communications ultrasound equipment is also essential, whether The IR section should also allow a close link with it comes from portable equipment or from a external diagnostic radiology and clinical servic- device fixed to the stand. es. Connections relate to the communication between the professionals implied, radiological The increasing use of MR for images and access to clinical patient information. guidance of interventions can “The recent A proper hospital network carrying clinical and lead to the association of biological information and images is essential. MR-equipment for angiogra- proliferation of phy. In addition to guidance, technologies poses Other Factors MR is in certain cases, the The installation of this kind of specialised area, only method that allows an financial challenges” should take into account additional peripheral immediate evaluation of the spaces: therapeutic result. This option necessitates the specific installation • Rooms for preparation of the patients requirements such as extended surface, specific • Boxes for ambulatory patients Faraday screen room, possibility of transferring • Post-intervention monitoring the patient between the two machines, machine • Rooms for radiologist and dedicated or not, separated access, compatible anaesthetist consultations material, etc. The recent proliferation of technologies that use certain physical agents for tissue The direct assumption of responsibility of patient destruction, has lead to a growing interest from care by the interventional radiologist, implies the the department of radiology, of acquiring diverse need for access to hospitalisation beds. equipment to perform radiofrequency ablations, cryotherapy, focused ultrasounds, etc., posing Equipment once more, difficult financial challenges to be Until the last few years, the basic equipment of solved by the department. an IR suite included angiography and later ultrasound equipment. The developments of core Conclusion interventional technologies revealed the need for The specific nature of interventional radiology, links in the same room of angiography equip- which necessitates specialised conditions, justi- ment with a slice-imaging technique. fies a great professionalism on behalf of the radi- The association of fluoroscopic real-time guid- ological discipline. This includes creation of a ance with a CT imaging device allows targeting specialised structure, its organisation, the choice by a 3D-guided puncture, followed by deploy- of methods of guidance and the choice of thera- ment of any therapeutic device. peutic agents. Those conditions can be only be created by collaboration between radiologists, These type of interventions can be carried out in industry, technicians, clinicians and hospital a CT room, aided by a portable fluoroscopy unit. administration. A synergy inside the department Conversely, access to the patient is difficult, the between the diagnostic and interventional activi- irradiation dose to the patient and staff is not ties is the key to success, and the best way negligible, and moreover, the conditions of asep- of preserving this activity within the house sis in such environments can be insufficient. of radiology.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 23 TTT Cover Story Interventional Radiology

CLINICAL CARE IN INTERVENTIONAL RADIOLOGY

Innovations Raising Standards of Healthcare

Minimally invasive procedures that began as “therapeutic alterna- tives” have now become first choice procedures, resulting in important changes in patient care. The clinical management of patients has altered with the progressive incorporation of these techniques and certain specialties such as surgery with the use of laparoscopy or gastroenterology with endoscopy have updated and even renamed their area of expertise. TTT of interventional radiologists has certain essential requirements. In general, current training pro- Unique Skills Called For grammes are based on a five-year model, preced- The development of interventional procedures ed by one year of clinical internship. The first within radiology has led to some idiosyncrasies. three years are devoted to a general core radio- The interventional radiologist, among other spe- logical training, and the last two are more flexi- cialists, has a detailed and unique anatomical ble to enable trainees to undertake more specif- knowledge, is trained in the versatility of the use ic training with a clear clinical objective. With this of different imaging methods and often finds scheme it is intended to obtain specialists that ways to carry out interventions with greater cost- all have basic radiological skills but who also efficiency. However, the daily programme of an have specific training either in general radiology interventional radiologist is primarily devoted to with the development of subspecialty interests or undertaking procedures and reporting them. The to focus on a single subspecialty. “agenda”, usually, does not include time for daily rounds, time to talk with the patient, to explain In this way, the system is adaptable to the needs the procedure or to evaluate clinical results. of different countries and hospitals, and is flexi- There are no established rules regarding training ble enough to include residents who have decid- requirements or resources needed, leading to a ed at an early stage their preferences. Some sen- low level of representation within the hospital. At ior specialists argue that, if the resident has present there are three areas in which an inter- decided, at the initial part of the training pro- ventional radiologist relates to the patient; per- gramme, to be an “interventionalist”, it is not so form the procedure in the best possible way; useful to follow specific areas of radiology focus our work within a multidisciplinary team in indepth but rather to have major involvement in which each does what they know best, and refer- more specific issues related to IR. Under general ral to the IR by the general practitioner (primary radiology training, in addition to the final two care physician). years, the third common core year should focus on training in the desired subspecialty. AUTHOR Better Training PROF. JOSE IGNACIO BILBAO Interventional radiologists require more extensive Improving Resident Programmes DEPARTMENT OF RADIOLOGY It is therefore essential to incorporate clinical UNIVERSITY CLINIC clinical training, so that they have a greater OF NAVARRA involvement in the direct clinical management of training modules within the training programme. PAMPLONA, SPAIN the patient. In order to respond to this, training In addition to the preliminary internship year, the

24 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Cover Story Interventional Radiology TTT

resident should have a structured period in which approaches should be discussed, as well as they can get experience in other disciplines such recent developments in treatment. This repre- as anaesthesia, surgery, emergencies or internal sents a proactive approach in the search for new medicine. During this period, the resident will patients and in offering our services to other spe- provide on-call cover to the relevant area. This cialists. training should be between eight to twelve New interventional radiology installations not months and should be additional to the five-year only should be well equipped and built to oper- radiology training programme. “Organ-related” ating room standards, but also have the space distribution of the departments should be gener- for running a clinic. Thus there will be a properly ally adopted with the aim of increasing clinical structured and equipped area where directly involvement of the radiologist and by offering an referred patients may be seen, information may increased clinical interchange with colleagues of be given to patients, post-procedure follow-up other specialties. Then, clinical training should be may be performed or any events that may arise incorporated in all the different subspecialty pro- may be dealt with. In the same way beds should grammes of radiology. be allocated for admitting patients.

A Specific Daily Schedule Reassessing Income Daily working schedules should be modified The income received for the procedures per- accordingly. Daily work in radiology departments formed should reflect the actual cost of the is scheduled according to assigned time-slots for whole process of patient care for the procedure each procedure. This includes both time needed and the skill involved in undertaking it. As the to perform the exam and to do the final report. therapeutic alternative to open surgery is, in For some radiological procedures this can be rea- many circunstances, a percutaneous-intervention- sonably predicted. With the incorporation of new al procedure, which may have similar clinical cross-sectional technologies with which the time results it is curious, that the payment for a surgi- to obtain the images is continuously decreasing cal procedure is very different (i.e., higher) to but, on the other hand, the time to do postpro- that performed by the interventional radiologist. cedural evaluation is clearly increasing, radiolog- Therefore the economical aspects of intervention- ic performance is neither easy to schedule nor to al radiology require review. evaluate. This difficulty is evident in IR, since pro- Few radiologist candidates will opt to enter a cedures have to be evaluated and discussed with training programme to learn percutaneous proce- the patient and other colleagues. Productivity dures if the payment systems remain as they are should not be evaluated exclusively according to at present. Not only because they get lower pay- the number of procedures performed but with ments when performing the same procedure as a other “indicators” such as their added-value or surgeon but also because they can often find bet- the impact that they have in adopting new deci- ter reimbursements if they perform a diagnostic sions for the daily clinical practice. study instead of a complex interventional procedure. The “interventional radiologist”, therefore must be properly trained for this task. At the same Final Requirements time, management should understand and recog- In conclusion the requirements and work pattern nise the time spent as an essential component of of interventional radiologists have a number of the procedure. The specialist should spend the differences from other radiological subspecialties appropriate ward and outpatient time to proper- and it is not a matter of comparing, but of under- ly prepare patients for the procedure and do fol- standing these differences. Productivity should low-up. not be analysed just by looking at the number of patients treated or procedures performed. If The Role of Multidisciplinary Meetings interventional radiology is to thrive it is neces- With this in mind, radiologists should attend as sary to address these issues in order to recruit many interdepartmental sessions as necessary. In new specialists and to provide satisfactory work- these sessions the different therapeutic ing conditions.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 25 TTT Cover Story Interventional Radiology

LEADING INTERVENTIONAL RADIOLOGY ACROSS EUROPE

Interview with Prof. Johannes Lammer

How did you come to be involved in EPOS. As you can see, our activities are very interventional radiology? multi-faceted, the main focus being education and research. I am currently a Professor of Radiology and the Director of the Department for Interventional What are the main issues concerning the Radiology, at the Medical University of Vienna. I development of interventional radiology in have always had a strong interest in intervention- Europe? al radiology, which is why I chose this specialty at a very early stage in my career. Due to this The main benefit of interventional procedures is

PROF. JOHANNES interest, I became very strongly involved in the of course that they are less invasive, which LAMMER activities of the Cardiovascular and Interventional results in lower morbidity and shorter hospital Radiological Society of Europe (CIRSE), which is stays, which means lower costs. The main obsta- CHAIRMAN, DEPARTMENT OF ANGIOGRAPHY AND the ideal platform for European interventionists. cles for the growth of interventional radiology is INTERVENTIONAL RADIOLOGY, Thanks to the support of my colleagues, I was not a lack of funding, however, but rather the fact UNIVERSITY OF VIENNA/AKH made Treasurer of the society in 2001. Two years that most people are not aware of these benefits. PRESIDENT OF CIRSE later I became its Vice-president, and following a This is a big problem, since interventionists often further two years, its President. depend on other physicians to refer their patients to them. Only a well-informed patient will ask for How is CIRSE leading interventional therapy across Europe? referral rather than leaving this decision exclusively to the referring physician or consult an Since CIRSE was founded in 1985, it has become the largest subspe- interventionist directly. Interventional cardiology cialty society in radiology, organising the largest non-cardiac seem to be a more developed science than inter- endovascular meeting in Europe every year. We have an excellent ventional radiology because it focuses on one Programme Planning Committee, headed by Prof. Michael Lee from organ only, which is why it is easier for the pub- Dublin, Ireland, ensuring we cover the latest topics in the field, as lic to understand. Furthermore there are simply well as new therapies, such as interventional oncology, carotid stent- more cardiologic patients ing, etc. Even though our annual congress is definitely the highlight of our scientific year, we carry out many more activities in the field What changes are essential for the future of of training and further education throughout the year. One of our interventional radiology? most important projects is the so-called European School of Interventional Radiology (ESIR), which consists of courses on inter- At present, there are general outlines of the ventional procedures held in different European countries. European Society of Radiology (ESR) for interventional radiology across Europe, which work very Is CIRSE active in the education of young interventionists? well, rather than having individual practice guidelines for every country. Also, every department of An important part of our educational activities are the CIRSE interventional radiology should have an outpa- Foundation education and research grants. Our education grants are tient clinic for the clinical examination of patients given to young interventionists who want to learn a new procedure and an in-patient clinic, i.e. a dedicated ward for and can only do so by completing part of their training at a different the procedures to be carried out. In the future, European hospital. With our education grants we try to encourage interventional radiology will replace many open research in Cardiovascular and Interventional Radiology, enhancing surgical procedures, such as vascular and onco- scientific knowledge and developing new interventional diagnostic logic surgery. Fortunately, there is no lack of res- and therapeutic techniques. Furthermore our society is drawing up idents who are interested in becoming interven- standards of practice documents and creating many opportunities for tional radiologists. The specialty is very attractive e-learning, such as E_IR (an online tool making educational material and it is easy for trained interventionists to find from the CIRSE Meetings available at all times) and a platform in a good job, since there is a strong need for them.

26 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES DIGITAL MAMMOGRAPHY Corporate Presentation

FUNDAMENTALS OF DIGITAL MAMMOGRAPHY Current and Future Advances in Mammographic Detector Technology

Andrew P. Smith, Ph.D.

New developments in detector technology and computers are altering the landscape of mammography imaging. Full Field Digital Mammography (FFDM) offers the promise of revolutionising the practice of mammography through its superior dose and contrast performance. Advanced applications made possible through digital imaging, such as automated computer-aided diagnosis and 3D tomosynthesis are expected to further improve diagnostic sensitivity and specificity

INTRODUCTION

New flat-panel X-ray detectors offer extremely high quantum efficiency and high resolution, bringing lower dose and improved image quality mammograms. Digital detectors for mammography can be categorised as indirect or direct conversion detectors. Indirect conversion systems suffer from resolution degradation caused by light spread in the scintillator, and from poor quantum efficiency caused by the use of thin scintillators. Direct conversion digital detectors utilise a direct- conversion method of imaging, wherein the X-rays are absorbed and the electrical signals MLO.Left - Screen Film Image MLO.Left - Digital Image are created in one step. The same patient imaged with the same radiation dose on a digital mammography and a screen-film system, shows the superior dynamic range of digital mammography. Systems using amorphous selenium represent the most advanced direct conversion technol- screen film imaging, 24 x 30 cm. Detectors selenium direct conversion detectors is seen ogy for digital mammography. Selenium is an that are the size of the smaller cassette, 18 x to be superior again to both screen-film and ideal material for a mammography detector, 24 cm, require imaging and tiling of many indirect conversion detectors. With superior because it has high X-ray absorption efficien- images to cover the field of view for larger DQE at all spatial frequencies, selenium detec- cy (approaching 100% at mammographic breasts. Detector performance is commonly tors offer the potential for both improved X-ray energies), extremely high intrinsic quantified by two metrics: Modulation image quality and lower patient dose. resolution, low noise and a well-established Transfer Function (MTF) and Detective manufacturing process. Quantum Efficiency (DQE). ADVANCES OFFERED FFDM SYSTEMS: MTF is a measure of resolution and DQE is a BY THE DIGITAL AGE FIELD OF VIEW measure of dose efficiency.The MTF for screen-film is superior to indirect conversion Digital images offer a variety of new and The field of view for FFDM systems is very detectors, while the MTF for direct conver- improved applications. The digital image pro- important. In order to be able to image most sion detectors are superior to both. vides image archiving and retrieval advantages of the adult female population, the imaging over film, and facilitates the use of computer- field of view must be similar to the size of the The DQE of indirect conversion detectors is aided diagnosis. Systems with high quantum largest screen-film cassette commonly used in superior to screen-film, however the DQE of efficiency, especially at increased X-ray ener-

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 27 Corporate Presentation

gies, offer the possibility of decreased breast for the specific clinical application. As the DIGITAL MAMMOGRAPHY compression. Future applications such as screen is made thicker, the cloud of light on DETECTORS stereo mammography, breast tomosynthesis, the film will increase in size, on average. This contrast enhanced digital mammography and reduces the resolution of the system, how- Digital technology offers the potential for other imaging modalities, are under investiga- ever the system’s sensitivity increases because several advances in mammography detectors. tion. Such advances will provide improved the thicker phosphor increases the probabili- Because images are captured as a digital signal, diagnostic information and reduced image ty that the incoming X-ray will be absorbed. electronic transfer and storage of images is confusion from overlapping structures. These Thus screen-film systems have a performance possible, eliminating physical storage and dis- 3D imaging tasks will benefit from the high trade off between speed and resolution. tribution required by film. Digital systems quantum efficiency that selenium detectors Because X-rays are absorbed with a decaying offer a large dynamic range of operation, offer.The digital detectors will also be able to exponential spatial distribution, in a screen- improving visualisation of all areas of the be used for full-field and high resolution film mammography system the film is placed breast and increasing exposure latitude. stereotactic breast biopsies and diagnostic imaging tasks. It is essential, however, that full- field digital systems perform its primary task well, i.e. breast screening. It is hoped that the potentials for improved image quality, lower dose and advanced imaging applications will result in improved diagnostic accuracy.

SCREEN-FILM MAMMOGRAPHY

Conventional film systems use intensifying screens to capture X-rays and reduce radiation dose. X-rays that pass through the tissue are collected by phosphor screens. These screens are often constructed of rare earth phosphors such as gadolinium oxysulfide (Gd2O2S) that output light upon absorption Indirect-Conversion Detectors utilize a layer to absorb the x-ray and generate of X-rays. When an X-ray is absorbed, the light photons, which are detected by a photodiode array. Light scatter degrades resultant light scintillation creates a number resolution. Cesium iodide detectors and Computed Radiography (CR) use this of light photons that spread and illuminate the technology. film in a distribution cloud. Film in close proximity to the screen captures the light photons, and the image is obtained by exposing the at the entrance surface of the scintillating Also, the digital format allows grayscale film.An important parameter to understand is screen.While a screen-film system offers sever- adjustment to optimise contrast for every the thickness of the intensifying screen. al advantages, there are significant disadvan- imaging task. Softcopy reading, computer- Thicker screens capture more X-rays and are tages; there is a narrow range over which it aided diagnosis and 3D imaging offer addition- therefore more dose efficient and higher can detect small differences in contrast; fre- al and potentially important opportunities for speed. However, thicker screens also create quently the entire image is poorly exposed improvement in mammographic systems. more light scatter and blurring of the image. because of film’s stringent requirements for Therefore, it is impossible to offer a screen- proper exposure, resulting in repeated imag- DIGITAL DETECTOR film system simultaneously offering the high- ing; film granularity affecting detective quantum TECHNOLOGY est possible resolution and lowest possible efficiency at high optical densities and visibili- radiation dose. This trade-off between radia- ty of microcalcifications; processing time and There are two methods of image capture tion dose and image quality must be optimised storage space. used in digital mammography that represent

28 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Corporate Presentation

different generations of technology: indirect Direct-Conversion Digital Detectors tors, the response function maintains its conversion and direct conversion. Direct-conversion digital detectors represent sharpness even as the thickness of the photo- a technological advance, eliminating problems conductor is increased, so there is no trade Indirect-Conversion Digital Detectors associated with light scatter inherent in indi- off between radiation stopping power and The earliest digital mammography systems rect conversion systems. In these systems, spatial resolution. Using amorphous selenium used a two-step process for X-ray detection. a photoconductor absorbs the X-rays and as the photoconductor, a thickness of 250 The first requires a scintillator layer such as directly generates the signal (direct conver- microns is adequate to stop more than 95% of cesium iodide doped with thallium [CsI(Tl)] sion). Under the influence of an external elec- the X-rays in the mammographic energy to capture the X-ray energy and convert it to tric field, holes (or electrons, depending upon range. Standard screens for use in film mam- light. An array of thin-film diodes converts the polarity of the applied field) drift towards mography only have about 50 - 70% quantum light photons to electronic signals captured a pixel electrode and are collected on a pixel efficiency, and the scintillator CsI(Tl) used in using thin-film transistors. Some systems, like capacitor.Because the charges travel along the indirect-conversion digital detectors exhibits Charge-Coupled Devices (CCDs), use alter- direction of the electric field lines, they move about 50 - 80% quantum efficiency. Systems native light collection and readout methods. In both systems, the light sensitive imaging function of film has been replaced by digital light imaging. It is in this sense that these can be seen as an evolution of screen film imaging. Similarly to screen-film, light scatter compro- mises image quality, and there is a performance tradeoff between spatial resolution and radiation sensitivity. As the scintillator is made thicker, light spread increases resulting in decreased resolution. Because of its colum- nar structure, CsI(Tl) does not create as much light scatter as other screens. However, compromise between resolution and sensitivity still exists.The placement of the scintillator is more problematic in indirect conversion digital detectors than with screen-film Direct-Conversion Detectors use a photoconductor to absorb the x-ray and systems. directly generate an electronic signal. No intensifying screens, intermediate processes, or additional steps are required. Selenium detectors use this technology. As with film screens, more X-rays are absorbed near the entrance of the scintillation layer than the exit. While film is placed without lateral charge spreading. This results using amorphous selenium can achieve almost near the entrance side of the scintillator, a in an exceptionally narrow point spread 100% quantum efficiency. The Hologic photodiode/transistor array is not transpar- response, of about 1 micron. The superior selenium detector is an example of direct ent to X-rays and the array must be placed on photoconductor for use in direct conversion conversion technology. the exit surface of the scintillator.This causes systems is amorphous selenium (a-Se). Andrew P. Smith, Ph.D, is a principle scientist at degradation in spatial resolution compared to Selenium has a long commercial history in Hologic, Inc., a women's imaging company. He screen-film.Typical thicknesses of CsI(Tl) used xerography, and its manufacturing processes attended the Massachusetts Institute of Technology in mammography detectors range from 150 are well known and optimised. Image quality where he received his Bachelor’s and Doctoral to 250 microns, and these indirect conversion of xeromammography systems was widely degrees in physics. digital detectors exhibit light spreading similar acknowledged, but suffered from reliability to screen-film systems. Examples of indirect problems. By depositing selenium on a flat- To receive the complete version of this article, conversion detectors are the Fuji CR plate panel imaging receptor, these problems have please contact Managing Editor Dervla Sains at and the GE CsI/TFT detector. been eliminated. In direct-conversion detec- [email protected]

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 29 Features

INCREASING OPERATIONAL EFFECTIVENESS Ensuring Stable Departmental Growth

To develop a quality-led, customer-driven and forward looking healthcare facility, heads of departments must implement innovative strategies to enhance clinical service, research, teaching, management, quality, safety, technology and revenues. Are patients fully satisfied? Is the available budget being used in the best possible way? Can enough resources be allocated to non-clinical aca- AUTHOR

PROF. J. L. BLOEM demic tasks? What about the future growth of the department? A key factor in meeting the demands HEAD OF RADIOLOGY AND of patient care, education and research, is having a holistic overview and strategy for developing NUCLEAR MEDICINE LEIDEN UNIVERSITY MEDICAL your department and identifying tools to increase this operational effectiveness. CENTRE LEIDEN, THE NETHERLANDS [email protected] What is Operational Effectiveness? Taking a controlled approach to development Operational effectiveness is the capability of pro- and change at an operational level means that ducing results according to specifications in a business product or workflow redesign should timely fashion (quality), using human and mate- only be carried out if the existing process is rial resources to result in adequate services for working sufficiently to cover the time needed to customers. It is the cornerstone of any successful implement change. The stability of any new inte- enterprise, which can be defined as one with gration takes time and planning. adaptability, wise use of resources and an ability to adjust to a rapidly changing external environ- For instance, it can be seen that 10% of all busi- ment, while maintaining its focus on core values. ness mergers fail because there is no integration There are four levels in the growth of an organi- at top level. In order to adapt infrastructure to sation: new, more sound strategies, operational effec- • Operational effectiveness: Is the department tiveness, i.e., the basic running of the depart- meeting at least minimum performance ment, should be optimised. This process is char- acterised by a singular focus on the department standards? and needs a top-down approach because a clear • Cost effectiveness: Is the department using direction, priorities, and speed are of the utmost available resources in the best way? importance. • Commercial effectiveness: Are customers satisfied? The next phase (cost-effectiveness) is also inter- • Strategic effectiveness: Are current opera- nally oriented but should also use the input of the working floor. Input from human resources tional strategies ensuring the future success lower in the organisation enhances the process of the department? of improving cost-effectiveness and also increas- Best Practice in Change Management es motivation. Motivation is one of the most important factors leading to success. The next One of the ways we can ensure that any changes two phases (commercial and strategic effective- implemented for the success of the department ness) are focused on the outside world and def- are solid and reliable, is to take them one level initely need the input of the entire department. at a time. Only when change has achieved its goal at each level should one consider moving on to the next. In this way, the process of devel- What Determines Infrastructure? opment will be swift, coherent and focused. If Operational effectiveness means that the product more than one level is addressed at the same lines (producing clinical output, research and time, the process will drain resources from day- education) of the enterprise run smoothly. At a to-day operations and become unstable. minimal level this is operational integrity, and at

30 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Features TTT

top level this means that a department meets tional standards, i.e., quality standards are being high internationally recognised standards. The met and the budget is being respected, this of infrastructure of the department is a major deter- course does not ensure that it is at its most cost- minant of operational effectiveness. As well as effective and therefore that the commercial and the availability and exchange of data, assets such future success and stability of the department is as human resources, technology, and budget are being maximised. all factors that determine the operational effectiveness of the existing infrastructure. Conclusion Prioritisation is the key tool when implementing Development and use of resources and informat- improvements or changes without undermining ics are therefore pivotal in improving operational the elasticity of the organisation. Elasticity is effectiveness. Only if operational effectiveness is the ability of the department to adapt or reached may the enterprise move to the highest even generate change, without damaging its levels of development. It goes without saying own structure. Using too much or too little that unless basic operational standards are met, elasticity will affect improvements to operational no other steps should be considered. Even if a effectiveness and is instrumental in keeping an department is meeting minimally effective opera- organisation vital and dynamic.

PART 2 LIVE 3D ECHO BRINGS REAL-TIME BENEFITS IN PAEDIATRIC CARDIAC CARE

Making a More Accurate Diagnosis

Advances in ultrasound technology are making it possible for physicians to obtain clearer images of the heart than ever before, which is critical in being able to accurately diagnose and provide appropriate treatment for young cardiac patients with congenital heart defects. From a business perspective, real-time three-dimensional imaging of the heart is enabling hospitals and clinics to improve workflow through faster exam times and improve their patient management and satisfaction.

In the field of paediatric cardiology, recent the young patient – and give surgeons an advan- advances in echocardiography have improved tage in pre-surgical planning. numerous aspects of care ranging from prenatal detection of heart defects to surgical planning. Prenatal Evaluation of the Foetal Heart Using STIC technology and Live 3D Echo, images Using STIC can be rotated and cropped to view the beating An emerging technology with great potential for heart from all angles. As a result, physicians are improving the detection rates of congenital heart able to obtain a complete view from multiple per- disease is STIC, or four-dimensional ultrasonogra- spectives, providing immediate and improved phy with spatiotemporal image correlation (STIC). perspective on spatial relationships. The full vol- AUTHOR ume datasets obtained from Live 3D Echo tech- In the U.S., guidelines for performance of foetal nology also facilitate more accurate quantifica- cardiac examination by the American Institute of DR. IVAN SALGO HEART FAILURE tion of heart function and ejection fraction; a key Ultrasound in Medicine (AIUM) recommends INVESTIGATIONS indicator of heart health. These tools assist the extending the examination beyond the four- PROGRAMME DIRECTOR physician in making a more accurate diagnosis of chamber view to include the outflow tracts of the PHILIPS ULTRASOUND

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 31 TTTFeatures

foetal heart whenever technically feasible. Improving Care for Children However, evaluation of the outflow tracts is the An additional benefit of Live 3D Echo is its rapid most difficult part of the extended examination of image acquisition time, which is advantageous in the foetal heart. scanning young children who cannot sit or lie still for extended periods. “Visualisation of the right and left outflow tracts is crucial for the diagnosis of cardiac anomalies And, since full-volume images can be manipulat- that affect the aorta and pulmonary arteries, and ed offline, additional scans are often not neces- for which morbidity and mortality can be sary. The quick acquisition time of Live 3D Echo improved by accurate prenatal diagnosis,” said also does not require sedation of children who Dr. Luís F. Gonçalves, Assistant Professor of might be anxious about imaging procedures or Obstetrics and Gynaecology, Wayne State who are too young to hold themselves still. University, Perinatology Research Branch NICHD/NIH/DHHS, Hutzel Women's Hospital, “Exposing young children to ionising radiation is Detroit, Michigan. always a concern in medical imaging,” said Dr. Shirali. “By using ultrasound, this concern is Indeed, many sonographers have difficulty eliminated, especially for patients that may obtaining and interpreting these views. Reasons require multiple exams as part of their diagnosis for this difficulty include lack of operator experi- and course of treatment.” ence, foetal motion during the examination, or the small size of the foetal heart. Why is 3D Ultrasound so Important? Congenital heart disease is a serious health Diagnosing and Treating Congenital problem. As the leading cause of death among Heart Defects congenital anomalies, the medical community Live 3D Echo ultrasound has shown real value in should strive to improve the detection rate for diagnosing congenital heart defects and helping these conditions. Tools such as 3D/4D ultrasound the paediatric cardiologist and surgeon plan life- have the potential to decrease the dependency saving surgery following birth. With 3D, volume on operator skills, speed up the diagnostic data can be archived and displayed in multiple process and improve diagnostic accuracy. planes as well as in rendered volumes, showing the motion of the cardiac chambers and allowing With time, it is likely that all ultrasound systems more accurate quantification of heart function. In will have 3D/4D capabilities as a standard addition, 3D Colour Flow allows the physician to feature. Accordingly, learning to quickly and better appreciate the blood flow through heart accurately extract the best diagnostic information valves and septal defects. is important for all physicians and clinicians as hospitals and clinics continue to improve patient Real-time three-dimensional imaging is proving care. to be instrumental in helping physicians better diagnose the exact nature of a condition and determine an appropriate course of action. Live Part Three of this series will appear 3D Echo is relevant to surgery or other interven- in the next issue of tions by providing the ability to obtain volumet- IMAGING Management: ric images of the heart, and to crop and slice those images real-time in a manner that was not possible before. By being able to view these images from relevant perspectives, surgeons now • Beyond the Heart: Innovations in Radiology have the ability to prepare a precise surgical As ultrasound technology continues to evolve, so plan, minimising surprises. “All these clinical applications can be done in a controlled, stan- too are the applications. From diagnostic applica- dardised manner, allowing for assessment of tions to treatment methods, we'll offer a look at heart anatomy and function more easily than the evolving applications already in development with 2D,” said Dr. Girish Shirali, Director of Paediatric Echocardiography, Medical University and how they can help clinics control costs. of South Carolina.

32 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES

TTTFeatures

POWER INJECTORS IN COMPUTED TOMOGRAPHY Increasing Medical Safety

Many Computed Tomography (CT) exams necessitate the use of intravenous injection of contrast media, to make specific organs, blood vessels or other tissue types stand out from surrounding structures. Until the early 1990’s, CT scanners employed long scan times using ‘step and shoot’ technology. To scan an average patient for the chest, abdomen and pelvis with 10mm sections at 15mm centres would require some 50 sections at 10 seconds each- about 5 minutes of scan time for a very breathless patient who has been asked to breath hold for 50 separate scans.

Initial use of contrast involved the radiologist in the scan room performing a hand injection of contrast media, typically 100 mls. It was only possible to acquire a relatively short number of scans with the contrast in the optimum circulatory phase and there were concerns about the consistency of timing and flow rates, which were very operator dependant.

New Technology Saves Time intracardiac right to left shunt). The volume of air The advent of slip ring technology allowed a scan may be a few mls. caused by not purging the to be acquired as a single volume of information, connecting line or may be as much as 100 mls., (spiral or helical scanners), reducing scan times if an empty syringe is inadvertently used. The to approximately 20 seconds per body area. second, extravasation of the contrast into the Multi-detector row scanners now allow scan times surrounding tissues, can cause damage due to of only a few seconds per body region. Many CT toxicity. This is usually very painful, and may protocols now require multiphase scans, where lead to breakdown of the tissues. CT injectors one body region is imaged with the contrast at currently on the market address these problems different circulatory phases, using a single con- in different ways but share many common trast bolus. New power injectors need to allow characteristics. tight control of flow rate, volume and timing of the injection. Recent developments in cardiac Characteristics of Power Injectors AUTHORS and angiographic CT have shown advantages in Flow Rate using a saline bolus following the contrast, - this is adjusted in steps of 0.1 ml. from 0.1 - MR. FRANK ELLWOOD reducing the volume of contrast required. Several 9.9/10 mls. If the flow rate is too high for the vein CT SUPERINTENDANT manufacturers are currently offering double head- being used it can cause an increase in pressure DERRIFORD HOSPITAL PLYMOUTH ed injectors in the UK market, including Medrad’s leading to venous rupture and resultant extrava- DEVON, UNITED KINGDOM Stellant CT Injector, Medtron’s Injectron CT 2 sation into the subcutaneous tissues. Injector, the E-Z-EM Empower CT Injector and DR NATHAN MANGHAT Tyco Healthcare’s Optivision DH CT Injector Delivery Pressure SPECIALIST REGISTRAR IN - to reduce the risk of extravasation it is essen- CLINICAL RADIOLOGY Safety Considerations for Power Injectors tial to be able to programme a maximum pres- DERRIFORD HOSPITAL As injections are often remotely triggered by the sure limit which may vary depending on size of PLYMOUTH operator in the CT control room, there are two the vein and flow rate of the injection. Once this DEVON, UNITED KINGDOM main safety issues. The first involves the injection pressure limit is reached, flow rate is reduced of air into the vein, potentially causing an air and a warning flashes on the screen. The opera- embolus in the pulmonary arteries or cerebral cir- tor then has the option to pause the injection to culation, causing a stroke (in the presence of an check that extravasation has not occurred.

34 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Features TTT

Volume Ranges saline and contrast concurrently and also has - different volumes of contrast and saline will be a ‘keep vein open’ feature. required dependant on the area being scanned, scan protocol and patient considerations such as • Tyco Healthcare’s OptiVantage DH has the weight of the patient and kidney function. All the ability to use prefilled syringes. According to above injectors have a maximum syringe size of a study by the American Society of Radiologic 200 mls. for both the contrast and saline sides. Technologists, the use of prefilled syringes was based upon four factors; saving time, Syringe warmer improving cost effectiveness, enhancing - To reduce viscosity, the contrast is pre-warmed healthcare quality and improving patient safe- to near body temperature which reduces adverse ty. This injector is programmable at the injec- effects. Once the syringe is positioned on the tor head and also features a tilt sensor/lock- injector it is kept at this temperature until out to reduce the risk of air embolus. This required. injector also has a patency check feature similar to the Medtron ‘keep vein open’ feature. Configuration - injectors are available as either ceiling- or Advantages of Intravenous Administration pedestal-mounted. In current practice, intravenous contrast is used almost universally for body scanning unless there Specific Features are specific clinical reasons or where contrast is • The E-Z-EM Empower injector has a patent- clearly unnecessary. If contrast is not used then ed patch, placed over the injection site that the soft tissues of the body cannot be distin- detects change of electrical impedance in the guished from one another. Contrast may be taken skin caused by extravasation and pauses the up by normal structures differently, depending procedure before harm is done. The device upon the nature of their blood supply, enabling registers extravasation volumes of less than us to appreciate differences. Diseased organs 20mls. This injector also has a tilt sensor/lock- may exhibit abnormal uptake or enhancement of out which prevents an injection unless the contrast. Upon injection of contrast through a injector is tilted vertically downwards beyond peripheral arm vein, contrast flows first through 270 degrees to help minimise the risk of air the right side of the heart, through the lungs, bubbles reaching the syringe tip. System arm- onto the left side of the heart and then out of the ing and flow rate manipulation can all be per- heart into the arterial system and perfuses formed at the injector head. through organs of the body. So it follows, that scan timing related to contrast injection rate and • Medrad’s Stellant injector has an automat- circulation time of the patient may allow imaging ed system for filling syringes with contrast of the organs in the circulatory phase of choice and saline and for advancing/ retracting the (Figure 1 a-c). syringe plungers which reduces loading/ unloading time and increases efficiency. Also, evaluation of blood vessels can be made There is a patented system to prime the very rapidly, with many invasive procedures now extension tube which controls waste and replaced by a CT scan. For example, the whole spillage of contrast and a ‘keep vein open’ heart may be scanned in less than 10 seconds feature which pulses a small amount of and we are able to evaluate not only the coro- saline to maintain vein patency. nary arteries but also gross morphological car- For cardiac scanning this system can inject diac structure and function. saline and contrast concurrently in order to provide images of the right side of the heart Conclusion with dilute contrast. The syringes used have CT is being increasingly used as a rapid, easily moulded fluid dots allowing easier detection accessible ‘one stop shop’ for the diagnosis of of air in the syringe. acute chest pain, which is a very common clinical presentation for a wide variety of potentially life- • The Medtron Injectron CT2 has overcome threatening pathologies. The prescriptive and the problem of trip hazards from electric careful approach to the use of intravenous con- cables by using a wireless touch screen trast use has become vitally important, as CT remote control. It has the ability to inject technology continues to advance at a rapid rate.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 35 ECRI E1

MODEL Analog Mammography HEALTHCARE PRODUCT COMPARISON CHART WHERE MARKETED FDA CLEARANCE CE MARK (MDD) GENERATOR TYPE High-frequency, ANALOG single-phase kV RANGE 22-35 mAs RANGE 4-600 MAMMOGRAPHY mA range Up to 100

PRODUCT COMPARISON CHART Time range, sec 0.02-8 AEC DETECTOR Yes Parameters controlled kV,mAs, anode/ filter X-RAY TUBE ECRI is a totally Anode type Rotating independent non Heat capacity, HU 300,000 Heat dissipation rate, HU/ min 60,000 profit research Target/ filter combinations Mo/ Mo, Mo/ Rh agency designat- Focal spot size, mm 0.1 and 0.3 CONTACT POSITIONING ASSEMBLY ed as a Collabo- Collimation Yes rating Centre of ECRI EUROPE 18 x 24 cm Yes 24 x 30 cm Yes WELTECH CENTRE RIDGEWAY, the World Health Organization (WHO). Movement locks Electromagnetic Such organisations are appointed to con- WELWYN GARDEN CITY, Assembly movement HERTS AL7 2AA, UNITED Rotation, -135 to +180 tribute to WHO’s public health mission by KINGDOM providing specialised knowledge, expert- Vertical, cm (in) 100 (39.4) [email protected] SID, cm 66 ise, and support in the health field to the WWW.ECRI.ORG.UK Scale guide Distance and WHO and its member nations. ECRI is pressure HANDSWITCH widely recognised as one of the world’s RADIATION OUTPUT leading independent organisations com- mR/ sec @ 28 kVp >800 RADIATION SHIELD mitted to advancing the quality of health- L x W, cm (in) care with over 240 employees globally. Thickness COMPRESSION SYSTEM Manual, automatic, fine adjustment

ECRI’s focus is medical device technolo- FOOTNOTES TO THE PRODUCT COMPARISON CHART gy, healthcare risk and quality manage- ON PAGES 32 - 34 ECRI E1 These recommendations are ment, and health technology assess- the opinions of ECRI's technolo- Force, newtons 200 ment. It provides information services gy experts. ECRI assumes no SCREEN-FILM SYSTEMS All (unless digital) liability for decisions made based and technical assistance to more than GRID RATIO 5:1 on this data. BUCKY For both film sizes Planmed P1 5,000 hospitals, healthcare organiza- Marketed in Japan by MAGNIFICATION DEVICE Yes Shimadzu Corporation. STEREOTATIC DEVICE Optional tions, ministries of health, P2 User-selectable normal AEC government and planning agencies, (mAs) or advanced AEC (mAs, kV); kV and thickness compen- FILM ID SYSTEM Yes voluntary sector organizations and sated; flex-AEC automatically LABEL PRINTER Optional accrediting agencies worldwide. Its data- selects sensors. POWER REQUIREMENTS P3 User-selectable normal AEC H x W x D, cm (in) bases (over 30), publications, informa- (mAs) or advanced AEC (mAs, WEIGHT, kg (lb) tion services and technical assistance kV); kV and thickness OPTIONAL ACESSOIRES compensated services set the standard for the health- P4 Complies with IEC 60601-1, care community. IEC 60601-2-45, IEC 60601-1-2 (EMC) and IEC 60601-2-28 (x-ray tube assemblies). Meets All of ECRI’s products and services are requirements of CSA, DHHS, and UL. PLANNING & PURCHASE available through the European Office, P5 autoload Bucky with List price, std configuration addressing the special requirements of MaxView/MaxView-ready units. GE Healthcare G1 This was valid only in Warranty Europe and the UK. Utilising some of the USA at time of publishing, which Delivery time, ARO world’s largest health related databases, might have significant difference Training to prices in Europe. Year first sold help, support and guidance can be given Hologic H1 Please note: The Affinity is Number installed to our European clients at a local level. CR compatible and meets Fiscal year European mammography OTHER SPECIFICATIONS requirements.

Publication of all submitted data is not possible: for further information please contact ECRI or [email protected].

36 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES PHILIPS MEDICAL

Nuance Classic P1 Sophie P1 Sophie Classic P1 Diamond

Worldwide Worldwide Worldwide Worldwide Yes Yes Yes Yes Yes Yes Yes Yes Constant potential, high-frequency, Constant potential, high-frequency, Constant potential, high-frequency, Single-phase, high-frequency, 3.6 kVA 80 kHz, single phase 80 kHz, single 80 kHz, single (2.5 kW) 20-35, increments of 1kV 20-35, increments of 1kV 20-35, increments of 1kV 15-39, increments of 1 kV 1-720 1-720 1-720 2-500 42 small focus, 120 large focus; available 42 small focus, 120 large focus; available 42 small focus, 120 large focus; available 30-100 with a tube that gives 35 mA with small with a tube that gives 35 mA with small with a tube that gives 35 mA with small focus and 110 mA with large focus focus and 110 mA with large focus focus and 110 mA with large focus 0.1-5 broad focus, 0.1-9.9 fine focus 0.1-6 broad focus, 0.1-9.9 fine focus 0.1-6 broad focus, 0.1-9.9 fine focus 0.02-10 Flex-AEC with 48 detectors Solid state with 3 independent sensors Solid state with 3 independent sensors AutoPoint, 8 discrete detector arrays mAs, kV P2 mAs, kV P3 mAs, kV P3 Time, kV, mA, filter, detector

Rotating, oil and fan cooled Rotating, oil and fan cooled Rotating, oil and fan cooled Rotating, dual-angle 300,000 300,000 300,000 300,000 56,000 56,000 56,000 60,000 Mo/ Mo, Mo/ Rh Mo/ Mo, Mo/ Rh Mo/ Mo, Mo/ Al; optional Mo/ Rh Mo/ Mo, Mo/ Rh, Mo/ Al 0.1 and 0.3 0.1 and 0.3 0.1 and 0.3 0.1 and 0.3

Automatic Automatic Automatic Automatic Yes Yes Yes NA Yes Yes Yes NA Motorized Motorized Motorized Motorized

+180, -135, motorized, isocentric, +180, -135, motorized, isocentric, +180, -135, motorized, isocentric, 185 adjustable speed adjustable speed adjustable speed 60 (23.5) motorized, adjustable speed 60 (23.5) motorized, adjustable speed 60 (23.5) motorized, adjustable speed 77 (30) 65 65 65 66 Digital display of force, thickness, Digital display of force, thickness, Digital display of force, thickness, Digital and angle and angle and angle Yes Yes Yes Yes

1,300 1,300 1,300 ≥840 Optional Optional Optional Yes 185 x 75 (73 x 30) 185 x 75 (73 x 30) 185 x 75 (73 x 30) 194 x 81 (76 x 32) 0.5 mm Pb equivalent or 0.3 mm 0.5 mm Pb equivalent or 0.3 mm 0.5 mm Pb equivalent or 0.3 mm 0.5 mm Pb equivalent Motorized, user-adjustable degressive Motorized, user-adjustable degressive Motorized, user-adjustable degressive Motorized, bidirectional ECS, speeds and force; manual compression, speeds and force; conventional and speeds and force; automatic or manual SoftTouch manual automatic or manual release of compres- Twincomp compression systems, automa- release of compression; digital display for sion; digital display for breast thickness tic or manual release; digital display for breast thickness and applied force; and applied force; optional MaxView breast breast thickness and applied force; optio- optional Twincomp or MaxView breast positioning system nal MaxView breast positioning system positioning system Selectable to 200 Selectable to 200 Selectable to 200 0-250 9 user selectable; 1 user configurable for AEC 9 user-selectable; 1 user-configurable for AEC 9 user-selectable; 1 user-configurable for AEC NA 5:1, 34 lines/cm 5:1, 34 lines/ cm 5:1, 34 lines/ cm 5:1, ROC equivalent 6:1 18 x 24 cm; 24 x 30 cm reciprocating 18 x 24 cm; 24 x 30 cm reciprocating 18 x 24 cm; 24 x 30 cm reciprocating 18 x 24 cm; 24 x 30 cm 1.6x, 1.8x, 2.0x 1.3x to 1.8x, motorized and continuosly adjustable 1.6x, 1.8x MultiChoice single device 1.6x, 1.8x, 2x Microprocessor-controlled Nuance Classic Microprocessor-controlled Cytoguide/ Microprocessor-controlled Cytoguide/ Delta 32 Cytoguide/Nuance Classic DigiGuide DigiGuide DigiGuide Network ID camera Network ID camera Daylight ID system or network ID camera Dataflash Plus optional Optional Optional NA 208-240 10% VAC; 50/60 Hz; 15A 208-240 10% VAC; 50/60 Hz; 15A 208-240 10% VAC; 50/60 Hz; 15A 198-264 VAC; 50/60 Hz; 16A 103 x 76 x 100 (40.4 x 29.9 x 39.2) 98.5 x 76 x 90 (38.8 x 29.9 x 35) 98.5 x 76 x 90 (38.8 x 29.9 x 35) 194 x 68 x 121 (76.5 x 27 x 48) 180 (396) 160 (352) 160 (352) 350 (771) MaxView breast positioning system, side Cytoguide, DigiGuide, network ID camera, Cytoguide, DigiGuide, network ID camera, 3-D imaging with TACT (tuned aperture access positioning system, Nuance Classic rectangular localization paddle with scale perforated or rectangular localization comp.tomography), specialty paddles Cytoguide/DigiGuide, network ID camera, and crosshair, high-lip compression pad- paddle with scale and crosshair, high-lip perforated or rectangular localization dle, MaxView breast positioning system, paddle, MaxView breast positioning sys- paddle with scale and crosshair, high-lip radiation protection screen, accessory tem, Twincomp compression, radiation paddle, accessory storage unit, shield, storage unit, CR interface, flex-AEC protection screen, accessory storage unit, turnable base, CR interface CR interface, flex-AEC

NA NA NA $137,791 G1 NA NA NA 1 year; parts, labor, and glassware NA NA NA 30 days NA NA NA 2 day, 16 CEUs NA 1991 1996 2000 NA NA NA 500+ February to January February to January February to January January to December Dual control panels; automatic Rh filter Dual control panels; automatic Rh filter Dual control panels; automatic Rh filter ParkBack tube head; AutoPoint automatic selection; fully automatic technique selec- selection; fully automatic technique selec- selection; fully automatic technique selec- detector selection; PaddleLogic; motorized tion based on tissue thickness and compo- tion based on tissue thickness and compo- tion based on tissue thickness and compo- cassette loading. Meets requirements of IEC sition; compact and transportable; auto- sition; compact and transportable; auto- sition; compact and transportable; auto- 60601-1, ISO 9001, MQSA, and UL. matic release; antiblooming (bias) circuit; matic release; antiblooming (bias) circuit; matic release; antiblooming (bias) circuit; automatic view angle; help-code display; automatic view angle; help-code display; automatic view angle; help-code display; built-in calibration and maintenance sys- built-in calibration and maintenance sys- built-in calibration and maintenance system; tem. P4 tem; autoload Bucky. P4 P4, P5

37 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES ECRI E1

MODEL Analog Mammography Lorad Affinity Series Lorad M-IV Series

WHERE MARKETED Worldwide Worldwide FDA CLEARANCE Yes Yes CE MARK (MDD) Yes Yes GENERATOR TYPE High-frequency, single-phase Constant potential, high-frequency, Constant potential, high-frequency, inverter inverter kV RANGE 22-35 20-39, increments of 1kV 20-39, increments of 1kV mAs RANGE 4-600 3-500 3-500 mA range Up to 100 10- 100 10- 100

Time range, sec 0.02-8 Up to 5 Up to 5 AEC DETECTOR Yes Solid-state Solid-state Parameters controlled kV,mAs, anode/ filter Automatic time/ kV/ filter Automatic time/ kV/ filter X-RAY TUBE Anode type Rotating Mo, rotating Mo, rotating Heat capacity, HU 300,000 300,000 300,000 Heat dissipation rate, HU/ min 60,000 60,000 60,000 Target/ filter combinations Mo/ Mo, Mo/ Rh Mo/ Mo, Mo/ Rh Mo/ Mo, Mo/ Rh Focal spot size, mm 0.1 and 0.3 0.1 (small), 0.3 (large) 0.1 (small), 0.3 (large) POSITIONING ASSEMBLY Collimation Yes Automatic Automatic 18 x 24 cm Yes Automatic Automatic 24 x 30 cm Yes Automatic Automatic Movement locks Electromagnetic Electromagnetic, fail-safe Electromagnetic, fail-safe Assembly movement Rotation, -135 to +180 +195, -155, digital readout +195, -150, digital readout

Vertical, cm (in) 100 (39.4) 71-140 (28-55) motorized 63.5-140 (25-55) motorized SID, cm 66 65 65 Scale guide Distance and Digital readout Digital readout pressure HANDSWITCH No No RADIATION OUTPUT mR/ sec @ 28 kVp >800 ≥800 >1,500, 60 cm RADIATION SHIELD Yes Yes L x W, cm (in) 185 x 60 (73 x 24) 190 x 80 (75 x 31) Thickness 0.5 mm Pb equivalent 0.5 mm Pb equivalent COMPRESSION SYSTEM Manual, automatic, fine adjustment Manual, motorized in both directions; Manual, motorized in both directions; precompression, full compression; dual precompression, full compression, dual footswitch compression modes; dual ,footswitch

Force, newtons 200 110-178 full compression, 300 manual 89-178 full compression, 300 manual SCREEN-FILM SYSTEMS All (unless digital) Up to 3, programmable Up to 3, programmable GRID RATIO 5:1 HTC or 5:1 linear, focused standard HTC or 5:1 linear, focused standard BUCKY For both film sizes 18 x 24 cm, 24 x 30 cm 18 x 24 cm, 24 x 30 cm MAGNIFICATION DEVICE Yes 1.8x 1.8x STEREOTATIC DEVICE Optional Stereotactic compatible Optional StereoLoc II

FILM ID SYSTEM Yes Rapid ID Flasher Integrated AutoFilm ID LABEL PRINTER Optional Optional Optional POWER REQUIREMENTS 200-240 VAC 10%; 50/60 Hz; 25 A 200-240 VAC 10%; 50/60 Hz; 35 A H x W x D, cm (in) 178 x 76 x 109 (70 x 30 x 43) 190 x 64 x 128 (75 x 25 x 50) gantry, 189 x 81 x 43 WEIGHT, kg (lb) 268 (588) 384 (800) gantry, 91 (200) console OPTIONAL ACESSOIRES HTC grid and FAST paddles (standard on HTC grid and FAST paddles (standard on platinum models), various compression platinum models), various compression pad- paddles, magnification table, localization dles, StereoLoc II, DSM, localization kit, kit; 10 cm coned down, aperture, view, or barcode reader, accessory cabinet, integrated integrated markers markers, MIS interface

PLANNING & PURCHASE List price, std configuration NA NA Warranty 1 year, parts; 2 years prorated, x-ray tube 1 year, parts; 2 years prorated, x-ray tube Delivery time, ARO ≥2 weeks ≥30 days Training 2 days on-site 2 days on-site Year first sold 2002 1996 Number installed NA 3,300 Fiscal year October to September October to September OTHER SPECIFICATIONS 18 x 24 cm SRL 2000 ;Bucky; 24 x 30 cm 18 x 24 cm SRL 2000 Bucky; 24 x 30 cm SRL SRL 2000 Bucky; HTC grids; FAST paddles, 2000 Bucky; HTC grids; FAST paddles, various various paddles; magnification platform; paddles; magnification table; face shield; full-field magnification; aperture; face radiation shield; AutoFilm ID; dual-function shield; radiation shield; Rapid ID Flasher; footswitch dual-function footswitch; auto aperture; Please note: The M-IV is CR compatible and integrated markers availableH1 meets European mammography requirements.

38 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES TTT OVERVIEW OF

HEALTHCARE IN HUNGARY Hungary Assessing Today’s Challenges Country Focus Country Focus

Imaging plays an integral role in medical care and compare well with current European figures. hospital management today. Unfortunately, imag- Diagnostic activities, included imaging are not ing is not considered a main priority for health- concentrated well. There are 154 hospitals for 10 care in Hungary at the present, and the common- million inhabitants in Hungary, with 84 thousand ly seen issues facing general medical care also beds in total. Active medical care is served by exist in imaging. Underfinanced medical care is 60,000 beds, with the remaining 24,000 for chron- the basic problem of the Hungarian health servic- ic and rehabilitation cares. This structure is not es. The medical care’s ratio related to GDP is only optimal. Many social problems have to be solved one third of the ratio compared to European coun- at medical level. Elderly people in all societies are tries in general, but in some fields even less. increasing in number and chronic hospice care Morbidity and mortality rates in Hungary do not demands are increasing steadily.

AUTHOR

Crises in Healthcare diagnostic and pathology. There are theoretically DR. IVAN GOLUB 40,000 physicians in Hungarian healthcare today, PRESIDENT OF ASSOCIATION OF An imbalance in the provision of healthcare has but only 34,000 of them are active in our coun- HUNGARIAN HOSPITALS DIRECTOR OF MAJOR DISTRICT significantly contributed to the above-mentioned try. In our hospitals 2500-2600 of specialists/con- AND TEACHING HOSPITAL sultants have fallen though the net due to the problem. Historically, Hungarian medicine is too UZSOKI hospital-centred. As a result of this, there are poor rewards on offer for an extremely demand- BUDAPEST grave problems in healthcare facilities other than ing job. However, the most worrying area is radi- HUNGARY hospitals, such as the structure of the system, ology, missing 30% of trained radiologists from financial problems, unequal access of patients to the system. medical care, not successfully managed during the past 15 years. Some reforms were initiated to Disharmonic regulations in healthcare provoke combat this during different types of govern- difficulties not only for imaging management, but ments. The result of this was a weakening of the for all hospital management and for medical care hospital sector and a failure of privatised gener- organised outside hospitals. European directives al practitioners in the old structure to take on related to workload and working hours and the more of the burden. vague legal status of doctors have added to trained workers leaving the profession. Some Imaging as well as healthcare in general is also variations of the legal status of doctors offered faced by a crisis of human resources owing to the flexible solutions to overcome the shortage of lack of financial reward in relation to other radiologists in hospitals. Recently these mixed European countries for healthcare workers. The employment versions became strictly limited, negative impact of this can be seen in diagnostic causing severe difficulties for imaging services in fields like radiology, nuclear medicine, laboratory hospitals.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 39 TECHNOLOGY OF THE 21ST CENTURY

Shimadzu Europa GmbH, Duisburg, Germany Phone: +49 (0) 203-7687-0 E-mail: [email protected] www.shimadzu.de

Reliability and advanced technology add value and increase safe diagnosis In 1896, just a few months after Wilhelm Conrad Roentgen’s discovery of X-rays, Genzo Shimadzu Jr. and Professor Muraoka of Kyoto University succeeded in taking the first “Safire” merges economic X-ray images in Japan. This was the starting point for a 110 with diagnostic benefits year long tradition in medical technology. Since then, the list Introducing the “Safire of success stories especially in X-ray technology is extensive. direct-conversion FPD” to Together with analytical instruments, medical technology has the medical sector turned Shimadzu into one of the leading suppliers world- enables digitizing of all Remote controlled table wide. The systems are at home equally in medical practices X-ray related diagnostic "Sonialvision Safire". and hospitals. imaging. This allows faster diagnosis, improved Today, Shimadzu develops, manufactures and distributes a diagnostic capabilities and accelerated remote medical broad range of diagnostic systems in all areas of clinical diagnostics. In Japan, over 100 "Safire" systems are already application – computer tomography, Digital Subtraction in use. The 23 x 23 cm (9-inch-square) or 43 x 43 cm (17-inch- Angiography (DSA), cardiovascular systems, digital radiography square) “Safire” FPD can be used both for still images and & fluoroscopy systems, ultrasound and general radiography fluoroscopy. Historically, for medical diagnostics, X-ray film has been used. But recently, with increasing implementation of digital and information technology in the medical field, the need for a high-resolution, high-sensitivity direct-conversion flat-panel detector has been keenly awaited as an appropriate X-ray detector for high-tech medical practices.

How does the "Safire" flat-panel technology work? Compared with the indirect-conversion flat panel, the new direct-conversion technology now creates clearer high-resolution images with less signal deterioration and reduced noise. The top layer of the flat-panel detector, an X-ray conversion film, converts X-rays passing through the patient's body directly into electric signals using amorphous Selenium. A TFT (thin-film transistor) array then collects the signal from each pixel and transfers the data immediately to the processing system. The direct-conversion flat-panel detector is far more sensitive Heartspeed with direct- conversion than conventional X-ray films. It produces still images as well Flat Panel Detector "Safire". as fluoroscopic images which are qualitatively equal to or better than film, even when the X-ray radiation emitted is reduced equipment. The latest developments include angiography from one half to one third of conventional X-ray examination. systems with C-arm rotation speeds of up to 60 degrees/second, This dramatically reduces the dosage exposure to the patient. two digital color Doppler ultrasound units and mobile X-ray systems. Shimadzu has traditionally invested heavily in research and development. The company has always followed a simple yet The next milestone in Shimadzu's X-ray technology is the vital concept: offering the best diagnostic system possible, so-called “Safire” flat-panel detector, the world’s first large combined with high patient- and user-friendliness. format FPD which converts X-rays directly into electronic signals using amorphous Selenium. Shimadzu medical systems are being used on every continent. The direct-conversion technology offers distinct advantages The experience gained all over the world is integrated into the in image quality and dose efficiency in comparison with indirect- design of new systems. Hence, every single user can benefit conversion flat panel. The current image amplifier technology, from the know-how gathered world-wide. inferior in image quality and dose efficiency, will soon become obsolete. Country Focus Hungary TTT

Problems of Diagnostic Radiology in Hungary European guidelines. New investments are needed in the near future. After decades of underfi- Diagnostic radiology in Hungary is insufficient to nanced healthcare without private capital this requirements due to shortage of staff and to the would be impossible. Private health provision in lack of high-tech equipment and infrastructure. Hungary is now only 20%. This level is highly Underfinanced healthcare in general and inability inhomogeneous. In some fields 100% private to cover the real costs of radiology are responsi- care already exists, in some other fields nothing. ble. Digital radiology for example is cost-effective Involvement of private capital has to be strictly for the long run, but bulk investment requirement regulated by the law. works against it. Hospital-based curative versus preventive health- Private diagnostic radiology centres are a good model of concentration of human and technical resources at cost-effective measures, but private radiology services have less participation compared to Hungarian radiology versus other fields of medicine, where higher percent of private capacities are available.

Raising the Standard

The centralisation of healthcare is the optimal strategy for reaching higher levels of medical service. Concentration of providers and techniques, and concentration of human resources could result in more cost-effective hospital care. A new structure is required based on major morbidity factors. The dominance of oncologic, car- dio-vascular and geriatric patients require specif- care is the norm in Hungary. Instead of rapid ic imaging facilities. changes in this field a longer period of development could result in a change of attitude for The centralisation of oncology – starting this year patients. Quality control and digital radiology, tel- – into major special centres is a good example of eradiology and telepathology consultations are a positive trend. Instead of compensating finan- most urgent requirements of the near future. cial support for these centres related to increased Collaboration of disciplines has to be coordinat- volume of patients, unfortunately financial ed at the level of hospital management. Also, the resources have decreased versus last year’s vol- heterogeneity of hospitals is too large. One third ume. The development of oncotherapy was wors- of hospitals are centralised major hospitals, help- ened this year by a drop in reimbursement levels ing in education ad postgraduate training organ- for oncology medication. Centralisation without ised by four university regions. compensation and without development is an example of how not to do it. On the other hand, Conclusion a reduction of health provision sites is not nec- essarily bad. This necessitates the clear planning In summary, instead of the incomplete and of capacity transfer in major centres based on the unproductive changes experienced in the opinions of the specialist’s professional boards. Huingarian healthcare system so far, well planned active development is required with sufficient Essential Changes financial support. Without investment no development can be reached. Rational and profession- Ownership and proprietorship must become clear al planning is required as well as more active par- and transparent rather than today’s confused ticipation in education and training. Effective mix: state governmental, local governmental, pri- healthcare has to be based on realistic estima- vate, foundation related, church related hospi- tion and coordination of both requirements and tals, etc. We need harmonisation in line with capacities.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 41 TTTCountry Focus Hungary

DEALING WITH ORGANISATIONAL CONFLICTS Challenges Faced by Department Heads

Radiology departments in the four Hungarian University Medical fessional activities of the radiologists and indi- rectly –via the cooperation of a chief technician – Schools (UMCs) are organised around three major tasks: patient the other employees. care, research and training (graduate, postgraduate and CME). The structure is organised accordingly; departments are directed by a Future Challenges We face three potential threats here: one is that University Professor acting as Chairman and at the same time as the number of residents entering radiology train- Head of the department. The focus of patient care activity of these ing has fallen behind the number of retiring radiologist specialists in the last decade; the other is departments traditionally exceeds the service provided for other that the private sector offers significantly higher departments of the medical school, and usually the department of wages to radiologists than the academic centres; radiology acts as a regional centre possessing the necessary skills the third is that it is more attractive for young specialists to continue their professional career and equipment for taking care of even the most difficult cases. abroad. Investment in teleradiology solutions may be of temporary help, but in the long run it may cause further difficulties, especially in the Role of University Radiology Departments field of research and graduate/postgraduate Training obligations are threefold in these cen- training. tres. The main duty is teaching radiology to medical students in the form of lectures, seminars Financial Concerns and practicals, not only in Hungarian, but – for The Head of the university department is respon- foreign students – also in English and German. sible for the budget, which is a difficult task because of the constant insufficiency of financing Departments of radiology are also responsible for healthcare activities (which is the main source of training radiology residents in their own premis- income) compared to other expenditure. Other es, and at the same time for the organisation of incomes, mostly resulting from training activities, training in all departments of their region. It is are not able to counterbalance the negative bal- also their duty to set standards and provide ance of the overall budget. Theoretically research opportunities for credit-based CME of radiolo- is funded by grants; however in practice the gists both locally and at a regional level. available university and other resources are Scientific activities are performed in the form of rather limited. The explanation of the fact that basic and clinical research in cooperation with despite all these difficulties it is still possible to other specialties, nowadays mostly in connection manage an acceptable level of function lies in the with computer applications (CAD), contrast mate- extremely low wages (On average per month; rial development, experimental neuro-imaging, neuro-tractography, functional imaging, etc. CT/MR Operator 300€, Radiology Resident 300€, Assistant Professor 750€, Full Professor Human Resources 1500€). The staff of an average university department consists of about a hundred employees, of whom The insufficiency of financing makes it extremely AUTHOR approximately 25% are medical doctors (cca. difficult to purchase the most up-to-date technol- twenty specialists and five residents), 70 % are ogy in these institutes, resulting in the controver- PROF. DR. ANDRÁS PALKÓ x-ray technicians, CT/MR operators, and nurses sy that rather typically the private centres and CHAIRMAN specialised in interventional radiology and the even some community hospitals possess high- DEPARTMENT OF RADIOLOGY end equipment much earlier than the university FACULTY OF GENERAL MEDICINE rest take care of PACS, computers, administration UNIVERSITY OF SZEGED, and maintenance. The Head of the department centres. This fact explains the unusual marriage HUNGARY directly controls the staffing procedures and pro- between university departments and private serv-

42 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Country Focus Hungary TTT ice providers, since that is how the necessary cal revolution both in research and training, while investments may find their path to the academic on the other hand they face increasing difficulties centres, which, on the other hand, have to to find the necessary funds and the appropriate- do their best to bring about a contract that guar- ly dedicated and enthusiastic staff to answer antees all important conditions indispensable these challenges. for ongoing high quality training and research activities. The solution to these problems may be to make the financial and technological environment in Conclusion the academic radiology departments much more University departments of radiology face many attractive, for which we have to achieve a change challenges: on the one hand they are at the front of paradigm in the attitude of politicians and line of all the actual turf battles and have to keep other decision-makers responsible for health pace with the ongoing scientific and technologi- care, higher education and research.

MANAGEMENT ISSUES IN A NATIONAL RESEARCH PROGRAMME A Multidisciplinary Approach

In South-west Hungary, three years ago, a regional imaging research programme was com- menced within the framework of the European Development Programme entitled “Management of Human Resources 4.3”. It was created using both funding from the University of Pécs as well as significant financial support from the European Community.

Aim of the Project both standalone and mobile diagnostic units The aim of this project was the establishment of including first line digital chest X-ray, digital a multidisciplinary screening and diagnostic cen- mammography, clinical screening of cervical can- tre of preventive medicine. While mortality rates cer, visual defects, musculoskeletal diseases, in Hungary remain among the highest in Western gastrointestinal bleeding, cardiac and vascular Europe, in the first phase actualised valid data of disorders. Second line diagnostic procedures are morbidity were the expected result. In parallel supported by full spectrum imaging modalities, with the existing project to improve the health from US to interventional radiology. The infra- AUTHOR services in Pécs another project was defined for structure is based on new equipments, like 64 PROF. ISTVÁN BATTYÁNI the integration of the different hospitals and out- slice MDCT, flat panel chest and breast x-ray and CHAIRMAN OF THE patient ambulatory systems. Scientific analysis ultrasonography, including echocardiography, DEPARTMENT OF RADIOLOGY and follow up of health indicators in the second vascular ultrasound and high resolution probes. FACULTY OF MEDICINE, phase were designed to prove the effectiveness Rotation DSA offers 3D angiography and is relat- UNIVERSITY OF PÉCS of integrated health services. The outcome of the ed to early diagnosis of cases leading to more PÉCS, HUNGARY research and management project is expected to cost effective interventional therapy. The mobile show disease prevalence based on more effective unit is in a truck with digital chest and breast X- patient management. The estimated improve- ray, medical office, gynaecological instruments, ment of health indicators in this way is 5 - 10% blood sampling, and a table to view visual in five years, without increasing costs, or even defects. using less expensive medical care. Management of the Centre How the Project is Set Up Management of the diagnostic centre is integrat- The screening programme consists of running ed in the University and coordinated with respon-

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 43 TTTCountry Focus Hungary

sible leaders from the city and county. Benefits for Undergraduates Management of the radiology service of the diag- The education of undergraduate students bene- nostic centre is integrated within the department fits from the existence of this diagnostic centre. of radiology, led by the Chairman. A very important lesson for them that will hopefully filter through the next generation of radiol- Management of the screening programme organ- ogists, is that a preventive attitude has to be ised by the preventive workgroup, consists of highlighted versus a conventional curative atti- representatives of all disciplines led by an admin- tude. Early diagnosis promotes more effective istrative coordinator. The project manager is inde- therapy for less expensive costs and offers better pendent of the University. Inter-departmental quality of life for patients after therapy. challenges related to collaboration in the diag- Information technology like PACS, RIS and HIS nostic screening centre have beneficial effects on within the University of Pécs is already complete, medical teams of different disciplines working and web based teleradiology (AccessNet, Aspyra) together. There is no doubt that these coordinat- is available for hospitals in the area. ed efforts bring colleagues together. This promotes collaboration in regular daily workflow as Expansion of the PACS will promote an integrat- well. ed healthcare service for the region. Medical safety considerations in screening have high impor- Quality Control and Budgeting tance. Modern equipment offers technical regula- Quality control and auditing is carried out within tory functions for dose reduction in general, but the framework of the University’s general rules. special low dose techniques especially for Special reports to EC Council are required also, screening programmes are already safe. The including coordinated plans for organising inter- majority of Hungarian radiological departments nal and external screening visits. In this system use nonionic contrast media. well organised multidisciplinary collaboration is required. The budget from the EC-supported Conclusion regional screening programme is allocated only The future of the project is dependent on a solid for investments, meaning that running costs have reimbursement structure, depending on interna- to be covered by regular reimbursement from tional scientific collaboration and publications. In health insurance. this respect we have developed trilateral scientific activities, as well as collaborations with Screening activity itself is not limited administra- other University Medical Centres. Numerous inter- tively by the health service on one hand, but no national studies are running in the Department, additional financial reimbursement is available on focused on thrombotic vascular diseases and the other hand. While an increasing number of oncological treatments. Each of these collabora- early diagnosed patients resulted from effective tions increases the modernisation of our health- screening, the reimbursement volume in Hungary care system in Hungary and cements the future is decreasing. development of this major national project.

DEVELOPING THE SCIENCE OF RADIOLOGY IN HUNGARY Experiences of a Department Head

As Head of the department of radiology since 1992 at the County Hospital of Zalaegerszag, I am part of a AUTHOR large hospital with a total staff of 1700 that is responsible for the medical care of a region that numbers DR. GYONGYI NAGY 301,000 inhabitants and covers a territory of 3784 km2. There are 37,000 inpatients per annum, and one HEAD OF DEPARTMENT OF million outpatients. A progressive policy towards medical care in the county means that there are three DIAGNOSTIC RADIOLOGY additional subordinated town hospitals in the county. In the department of radiology, we aim to create a COUNTY HOSPITAL ZALAEGERSZEG structured and transparent healthcare service that benefits from proactive working collaborations with HUNGARY other clinical partners, which is also extended to educational and scientific activities.

44 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES Country Focus Hungary TTT

Technical Development phers on duty in hospital and on call support of In 1992, the hospital was privileged to receive subspecialists is available for example in case of investment to purchase brand new radiological cholecysta drainage. Morning meetings of the equipment including dual-slice CT and 1,5T MRI fourteen radiologists offer the chance for reeval- devices. Four ultrasound machines (two of them uation of the cases as they develop during the with colour Doppler, one with breast specifica- night. tions) are also available.

Organisation of Staff Subspecialist head radiologists and radiographers are spread over eleven divisions. Others are rotated with partial overlapping to preserve multifunctional skills. Six radiologists carry out diagnostic and interventional DSA, ten doing CT, seven doing MRI and four responsible for breast examinations. Neuroradiology and paediatric radiology divisions are staffed by board certified subspecialist radiologists. Clinico-radiological teams are brought together once a week to discuss areas such as gastrointestinal, breast, and oncological subjects. In our department, clinicians are focusing on a holistic approach to diag- Teleradiology nostic problems rather than taking a narrower Teleradiology from home is not yet available view of particular modalities. The most appropri- here, however via the hospital, we have in place ate modality for each clinical question is decided a system to obtain second opinions from univer- by the radiologists based on cost-risk-benefit sity centres and national institutions on difficult estimation. Imaging modalities that are to be cases. Clinico-pathological meetings and regular applied to each particular diagnostic strategy are smaller follow-up meetings of cases with retro- discussed with the nuclear medicine team as spective reevaluation help decrease misdiag- well. A variety of ultrasound investigations, like noses, mistakes and errors. There are study pro- transcranial and carotis Doppler, gynaecology tocols and regular meetings for revisions, where and obstetric exams, echocardiography and car- radiographers also participate. We also hold diologic catheterisation are carried out by clini- postgraduate educational meetings for radiogra- cians using equipment from their own individual phers. departments. Scientific activities are also dealt with by clinico-radiological teams. Twice a week Challenges Facing the Department we have set up radiological journal referees by The National Insurance Reimbursement Policy is our staff members. Educational meetings are also the main problem faced by department manage- held weekly for our residents in training. This ment in recent years, restricting the upgrading of year the national meeting of radiology residents equipment and general development of the was organised by the Zalaegerszeg staff. department itself. Also, since department regulations are not standardised and are frequently Quality Control changed, it is impossible to create a true long- Since 1996, quality control in our department is term strategy. Unfortunately restrictive financial based on ISO 9001:2000 certification. Twice a support have resulted in significant limitations in year administrative and practical audit proce- the provision of diagnostic and therapeutic care dures take place. Good collaboration with hospi- this year in Hungary, something which looks tal management and with both regional adminis- unlikely to change in years to come. tration and health authorities promote a financial balance that make it possible to run US, breast, However, working with available technological CT, MRI and DSA in two shifts with daily sched- and human resources, we have managed to cre- uled patient numbers of fifty in CT and forty-five ate an organised and systematic process which in MRI. During the night urgent investigations are allows the best possible patient care we are able dealt with by one radiologist and two radiogra- to provide, despite limitations.

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 45 How To... HOW TO... ASSESS A BID WHAT TO LOOK FOR BEFORE YOU BUY

In the department of radiology here at the UMC St. Radboud, we have in place an eight- to ten-year investment plan that covers which apparatus needs to be replaced. We have three streams of budget for capital outlay. We reserve 10% of the total value of our current equipment for maintenance and upkeep. We also have budgets for expansion and replacement of AUTHOR equipment which are renewed every seven to ten years. The key factors when assessing a PROF. HANS BLICKMAN bid, are being thorough, knowing your needs and the capabilities of the equipment, having

CHAIRMAN, DEPT. OF RADIOLOGY an accurate inventory and linking the functionality of the equipment to the specific needs UMC ST. RADBOUD, NIJMEGEN of the user. THE NETHERLANDS [email protected]

How to Assess a Bid somehow find a way to charge you or you really need a high-tech device or The process involves the following steps: incorporate any costs into the total will it just be used once a week? 1. Assess in what areas new apparatus package. As we are an academic hospi- need replacement by liaising with tech- tal, one of the ways we try to have Obsolete Equipment nologists and radiologists in that partic- added value is by requesting extra func- We are also involved in a programme to ular area. tionality or software packages, e.g. with refurbish obsolete equipment which has 2. A plan is submitted to a dedicated a recent CT purchase we requested a vir- outrun its lease and depreciated to the budget control committee, who then tual colonography package thrown in at point where it has no inherent financial issue a budget based on list prices from no extra charge. Another example is that value. Normally it is policy to return such manufacturers. recently when we purchased a CT scan- defunct equipment to the manufacturer 3. If that sum is greater than EUR275k ner for our emergency room, we incurred who in theory has factored its return per item, we initiate an EU bid process extra costs since the room had to be into the initial cost of the equipment, in Brussels. There are two timeframes remodelled in order to place the but since the last four years we have for this process, the first allows vendors machine. The vendor agreed to pay half been sending the apparatus instead to 21 working days in which to tender bids, of these refurbishment costs in order to the former Yugoslavia. Just recently we and the second allows 52 days including make the sale. sent a nine year old MR scanner for weekends. Which process we choose refurbishment in Berlin where it will after depends on the urgency of the bid. For Turf Battles be sent for use in Belgrade. example, for routine equipment needs When assessing a bid, inter-departmen- we choose the 21 day cycle. However, if tal conflicts may arise when choosing Conclusion we are purchasing technology which which equipment needs are of highest If the Chair of an imaging department is needs more thorough investigation, we priority. A major issue for us presently to make the wisest and most informed allow more time to reevaluate and adapt involves the use of ultrasound in our choice when assessing bids from manu- our needs. medical facility. Although our imaging facturers, cost is not always the most 4. A special bid assessment committee department uses eight ultrasound useful barometer. Rather than leaving then uses a points system evaluating machines, there are a total of seventy in final purchasing decisions to the head of each offer that takes a thorough analy- the medical facility as a whole, not all of the imaging department, I am a firm sis of each of the pros and cons which are placed in the best way for the believer in making equipment purchas- involved. The one that fits most of our needs of the user. We are looking at ing decisions on a democratic basis. By criteria is the successful bidder. If there ways in which to reorganise the distribu- listening to the needs and recommenda- is a tie in scores between two bidders, tion of equipment so that it suits the tions of appropriate team members, and we then ask the radiologist or technolo- needs of the user and so that high-tech using dedicated committees whose role gist involved what their ‘pre-bid prefer- apparatus is not allocated to a depart- it is to oversee the continuing growth of ence’ is and we look at added-value ment that has no need for the extra the medical facility as a whole, the most areas such as after-sales service. specifications. While the individual appropriate equipment, which is most department may be content to purchase likely to provide the best outcome in Getting Added Value the highest-spec equipment, significant terms of providing necessary healthcare What added value can we ask for from costs can be saved by placing equip- within financial guidelines, will finally be manufacturers? As negotiating tools, ment by linking function to a more real- selected. options are limited, as mostly whatever istic view of needs. Assessing cost/per- extras vendors allow you, they will formance ratio can be helpful here. Do

46 P ROMOTING TEAMWORK ACROSS DIFFERENT DISCIPLINES My Opinion

INTERVIEW WITH PROF. GEORG BONGARTZ

Tell us about the background and How does MIR address its origins of MIR. multidisciplinary audience? Four radiologists (Paolo Pavone, Italy, Besides clear management topics, Christian Herold, Austria, Gabriel Krestin, technical issues in radiological manage- The Netherlands and myself) formed the ment like data handling and processing “European Working Group on are included into the scope of topics. Management in Radiology” (EWGMR) in With this, the entire PACS, RIS, INTERVIEWEE 1994, to support young European Telemedicine, etc. discussion is part of Radiologists in the development of man- the concept. We try to balance this out PROF. GEORG BONGARTZ agement skills. The idea met with strong and highlight the management aspect of HEAD GENERAL RADIOLOGY support from major pharmaceutical com- these purely technical topics in radiolo- UNIVERSITY HOSPITAL BASEL panies including Schering, Guerbet, gy. This mixture makes the MIR congress SWITZERLAND Nycomed – now GE, and Bracco. The first unique. workshops were not only financially supported by them but also guided by sen- Why is MIR such an important ior management from the companies. annual conference? Later, the scientific aspect of manage- work, the interpersonal contacts and the Good knowledge of management ment was taken up by EWGMR and the entire social part of our work is endan- tools, the insight that your problems are first Management in Radiology (MIR) gered. Leading a department via elec- identical to those of others and some congress took place in 1998 in tronic communication is extremely diffi- guidance in how to deal with them is Strasbourg. The European Association of cult because personal contacts are still offered in presentations, discussions Radiology (EAR) found the initiative very one of the main motivators and visibili- and handouts. The intense exchange of attractive and offered the EWGMR a ty is mandatory to keep contact with co- personal knowledge and the creation of “new home” as subcommittee to the workers. We all must face the problems an international network to identify peo- Professional Organisation Committee of in the new communication systems and ple that you can ask for help in certain EAR, now ESR. address them properly. For this reason, situations appear the most important one of the skills we focus on in manage- Has the organisation of the MIR reasons for people to attend the meet- ment workshops is how to be both ings. annual congress changed since it Chairman and a balanced social manager at the same time. began? What future plans for the develop- The annual workshops and meetings ment of MIR are in place? Is today’s emphasis on productivi- were successfully organised by our office I hope MIR will gain even larger ty in healthcare negatively impact- in Rome, by Antonio Santoro. Supported attention and will be a regular part of ing good management? by his proactive organisational skills, the the annual ECR conferences. More and At first glance, yes. But this is one of initiative became more and more profes- more workshops shall be organised to the challenges to address. Although sional. As a result the organisation is bring education in management closer being competitive can be seen as nega- now being transferred to the central ESR to all European radiologists. Within the tive, it also produces creativity and office in Vienna under the guidance of ESR, MIR will probably rise to an inde- awareness. Healthcare today is a chal- Peter Baierl. Henrik Silber will organise pendent committee of ESR. the next meeting in Oxford 2007, under lenging industry where not only the indi- new incoming MIR Chair, Dr. Nicola How have new management tools vidual patient must be taken care of but also the entire community as “stake- Strickland. The MIR board has devel- like PACS, teleradiology etc. oped official guidelines; chairmanship holders”. The incentive for the individual lasts two years and the appointment to impacted Chairmen and Managers? radiologist is not only to be acknowl- the board four years. From the initial Strongly! Our working life is now get- edged as an “experienced radiologist” founding team, only Paolo Pavone and ting away from personal teaching and but also to be successful and straight- myself are still involved, and both of us contacts and more into office-based forward in your business: to have active will roll out 2007/2008. work. Communication takes place by and motivated co-workers, a high-level writing emails and reporting by electron- infrastructure and to be able to cooper- ic media. While all this may positively ate at an interdisciplinary level. affect workflow and the quality of the

IMAGING MANAGEMENT: THE O FFICIAL VOICE OF THE E UROPEAN I MAGING I NITIATIVE 47 TTT Agenda

Key Seminars & Conferences

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