The future of radiology:
capacity challenges, networks
and artificial intelligence?
RAD Magazine, 43, 500, 47
Professor Erika Denton
Associate medical director, honorary professor of radiology,
Norfolk and Norwich University Hospital
It has been an ongoing topic of conversation in
radiological circles over many years as to whether
imaging services as we know them really have a
future. I am often asked if other clinicians or
indeed computers will take over from radiologists
and perhaps whether robots could take over from
radiographers and radiologists. I genuinely do not
believe this to be the case in the foreseeable
future.
At a time of unprecedented financial constraint on healthcare expenditure in England and an ever-increasing, longerlived, elderly population with many comorbidities which
require imaging investigation, radiology services have never
been under greater pressure. The challenges for imaging are
also increased as patients become better informed, primarily
because of easy access to digital information and advice.
Current NHS capacity is not able to cope with growing
demand for radiology. Figure 1 shows the year-on-year
increase in imaging activity in England. There are also fewer
radiologists per head of population in the UK than in the
rest of Europe as shown in figure 2.
For English radiology departments, recruiting new consultant staff can be very difficult and there are vacant consultant posts in many hospitals, particularly smaller and
more geographically isolated departments, while larger hospitals and training centres succeed in recruiting and have
the potential reporting capacity.
Figure 3, from the Royal College of Radiologists (RCR),
shows the number of declared consultant vacancies across
England in 2015.
As we struggle to manage ever-increasing demand with
the constraints of slower increase in the workforce, we have
to think of ways to deliver the service we are so proud of
more efficiently, using our resources to best effect. In recent
years the NHS has been the focus of many publications by
government, and radiology has been under pressure to not
only deliver much more with no increase in budget, but also
to deliver things differently in line with political imperative.
The latest NHS England sustainability and transformation
plans (STPs) across 44 geographical areas in England give
yet more challenges and, depending on your perspective,
either threats or opportunities for new ways of delivering
our services.
The imbalance between radiology service provision and
capacity to deliver was the focus of a 2015 survey undertaken by the RCR. All radiology departments in England
were asked for details of their waiting times to deliver radiology reports; 73% of hospitals in England had some patients
waiting longer than 30 days for imaging reports and at any
one time around 13,000 patients were waiting over a month
for CT or MR reports, with 175,000 unreported x-rays. This
is clearly unsatisfactory for both patients and referring clinical teams, has potential patient safety risks and puts
increasing pressure on already over-stretched radiology
departments.
The ability to network imaging departments, so linking
reporting capacity using technology, is an obvious way to
maximise existing resources. Over the next few years it is
likely that the traditional boundaries between hospitals will
be broken down by the availability of reliable, flexible, sustainable and locally adaptable digital platforms which will
enable us all to work closely with each other regardless of
geographical boundaries. This will also facilitate our ability
to provide high quality care for patients at all times of the
week – a clearly articulated current political objective.
High quality versatile teleradiology services are established in the UK and across Europe using reliable and flexible personnel and resilient technology solutions. A recent
ESR survey confirmed that across Europe over 70% of radiologists report that their hospitals use out-sourcing and this
market will be worth approximately £5bn globally by 2022.
The same survey also describes the negative sides of teleradiology with 30% of European radiologists feeling that
teleradiology devalues radiology as a profession and a similar
number believing local radiologists provide a better service.
A probable solution to the current capacity challenges for
English radiology departments is to create clinical networks
of radiology departments to provide timely and expert radiology services for patients across their geography regardless
of the location of the patient. These are likely to follow the
new STP footprints and will address the concerns about outsourcing by using local radiology teams.
In England, the Image Exchange Portal (IEP) has been
very widely used over the last decade as a cost-effective way
to share images between departments. The IEP does not
historically have functionality to be used as a reporting or
workflow management system or to share large volumes of
data. Teleradiology experience and the existing technology
platforms can, however, be used to deliver fully functional
networked imaging and other diagnostic services between
hospitals – effectively local insourcing. These enable radiology (and also digital pathology) reporting workload sharing
across geographical and institutional boundaries. The East
Midlands experience establishing a large local radiology network is the best developed in England to date (EMRAD) but
it is currently still ‘work in progress’ as the systems become
established and new ways of working between institutions
develop.
Computer aided diagnostics (CAD) has been an area of
focus for many with research interests in radiology but has
yet to gain a significant place in our routine workflow. I
anticipate that this rapidly developing technology with artificial intelligence (AI) at the heart of digital image interpretation is very likely to become part of our ‘business as usual’.
In the USA CAD systems have been used for many years
by breast radiologists reading mammograms and the payment system has influenced this significantly by reimbursing
at higher levels where CAD is used. In UK mammography
CAD has not become established as the gain in sensitivity
is relatively small and the loss of specificity significant for
high volume radiology practice. AI does however have the
potential for significant improvements in diagnosis in other
areas of digital image analysis.
So called ‘deep learning algorithms’ or machine learning
systems are being developed by IBM in its Watson Health
programme, Google with DeepMind and General Electric to
name just three of the plethora of interested industry partners and their associated research groups. Current successes
include detection of pneumothorax; automated analysis of
echocardiography images; automated retinal image analysis;
pulmonary nodule risk prediction; radiotherapy planning
Year-on-year increase in imaging activity in England
45
Number of examinations (millions)
40
35
30
25
20
15
10
5
0
95-96
96-97
97-98 98-99 99-00 00-01
CT
MRI
01-02 02-03 03-04 04-05 05-06
Ultrasound
Radioisotopes
06-07 07-08 08-09 09-10
Radiographs no fluoroscopy
10-11
11-12 12-13
13-14
Fluoroscopy
Figure 1
and combining imaging findings with data from the whole
care record to more accurately predict the likely diagnosis.
It is easy to perceive AI as a threat to radiology or even
that its use will lead to the demise of radiologists. I disagree;
in a world where the driverless car is very much a reality
AI will help radiologists perform better and we should shift
our focus from fear and concern to interest in how deep
learning can improve what we do and replace the more
monotonous aspects of image interpretation.
A combination of AI and networks of highly skilled radiologists joined in an effective online working environment
has the potential to address some of our capacity challenges.
I anticipate that neither will address this completely and
increased numbers of radiologists will continue to be needed
and will have fulfilling and exciting jobs for many years
to come.
Declared consultant vacancies across England in 2015.
From the Royal College of Radiologists
Further reading
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www.england.nhs.uk/ourwork/new-care-models/vanguards/caremodels/acute-care-collaboration/emrad
www.emrad.org
www.ibm.com/watson/health
itnonline.com/content/smart-scanners-will-ai-take-controls
deepmind.com/applied/deepmind-health/research
www.fastcompany.com/3065572/body-os/paging-dr-algorithm-ge-and-ucsf
Radiologists per 100,000 people in western
European countries (2011-2012)
18
16
14
12
10
8
Figure 3
6
4
2
Figure 2
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