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Editorials |
1 From the Department of Diagnostic Radiology, Mayo Clinic, 200 First St SW, E-2, Rochester, MN 55905. Received February 12, 2003; accepted February 14. Address correspondence to the author.
Index terms: Editorials • Images, hard copy • Images, interpretation
The clinical assessment and follow-up of patients with known hepatic metastases or patients at risk often necessitate the use of abdominal computed tomography (CT). Depending on the type of primary malignancy, a CT scanning protocol can include image acquisition prior to or during the arterial dominant phase, during the portal venous dominant phase, and, occasionally, with a delay of several minutes after administration of intravenous contrast material. Advanced CT capabilities also allow image acquisition at narrow section collimation to be combined with multiphase acquisition. These acquisitions combined generate an enormous number of images that must be reviewed efficiently. Not long ago, a standard liver CT examination would include approximately 15 1-cm sections acquired during the portal venous phase of contrast enhancement. Today, that same liver examination could yield 240 images or more. In many practices, soft-copy evaluation involving the use of commercially available workstations has solved many of the issues related to handling and reviewing this large quantity of data. The role of hard-copy interpretation is disappearing rapidly as a practice necessity.
In this issue of Radiology, Dr Pijl and colleagues (1) provide a welcome comparison between soft- and hard-copy interpretation in patients with hepatic metastases. They have demonstrated that interpretation is faster by using soft-copy tools without a reduction in lesion detection. In fact, there was a trend that indicated improved detection of both intra- and extrahepatic disease by using soft-copy review. In addition, a trend indicating improved interobserver agreement and reader confidence with soft-copy evaluation was also observed. The authors correctly attribute the larger image size and the variable display options (display rate and window settings) as advantageous factors inherent in soft-copy evaluation that might account for their findings. Other investigators have reported similar findings when comparing soft- and hard-copy evaluation in the assessment of other clinical problems (2–9).
Other advantages and disadvantages exist as soft-copy evaluation is implemented within a radiology practice. Improved physician efficiency with use of soft-copy interpretation is of critical importance as equipment costs and clinical practice demands increase, while the pool of available radiologists remains limited. Every practice I am aware of expects and demands more production from every member of the radiology team. Confirmation of improved practice efficiency for the radiologist in this article is welcome news. Some of the additional advantages of implementing an electronic or digital practice include the ability to network problematic cases to experts who are located at geographically different sites. As an abdominal radiologist, it is helpful to gather the opinion of a chest or musculoskeletal radiologist when encountering equivocal changes in the lungs or skeleton of a patient. The quality of interpretation is improved.
In addition, soft-copy evaluation allows the radiologist to implement tools available on the workstation that could never be used on demand with hard-copy film. For example, reformation of CT data is becoming commonplace for specialized examinations like CT and magnetic resonance angiography and CT colonography. As radiologists become more comfortable with these display tools, I believe that interrogation of image data beyond standard transverse images will become common practice. Furthermore, new tools can be added to workstations to assist radiologists with online interpretation. Computer-aided diagnostic tools are being developed and used in a variety of applications today (10–14). These tools will become part of our future daily practice—seamlessly integrated into our soft-copy review. Finally, video presentations of stacks of image data can be exported easily from a workstation for demonstrations and case presentations. These presentations provide the same level of improved reader confidence and review efficiency to others that soft-copy interpretation lends to the initial reviewer.
The disadvantages of widespread soft-copy review are hinged mainly on the high costs associated with the required digital infrastructure. Although such a discussion is beyond the scope of this editorial, it is important to recognize the high level of commitment required for an enterprise-wide system. In addition, the requisite transition from hard-copy (film-based) to soft-copy (filmless) evaluation requires a costly dual environment (of variable duration) to support both film and soft-copy review. Despite these disadvantages, the long-term prospects of a filmless environment and soft-copy review seem to be inextricably linked to the future success of radiology.
Many challenges remain as we convert to soft-copy interpretation. A critical one is developing support for this change from referring clinicians. Providing them with efficient access to the image data and interpretation is key to obtaining their support. In addition, clinicians want help sorting through the voluminous data so they can rapidly access the images that are pertinent and understandable to them. Better tools are needed to accomplish this important task.
Pijl et al (1) have provided abdominal radiologists with substantive data that support a practice change to soft-copy evaluation. There are many advantages of such a change, but the costs are high and require careful planning and commitment. These advances promise an exciting future for radiology by providing improved care to our patients and service to referring physicians.
FOOTNOTES
See also the article by Pijl et al in this issue.
REFERENCES
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