medical solutions december 07 rsna

The Magazine for Healthcare Leadership

December 2007

Medical Solutions

Beyond TechnologyFuturist John Naisbitt on Innovation

Breast CancerComprehensive Solutions

Answers for life.

Our latest breakthrough technologies streamline your clinical processes. Innovating every step of your workflow.It’s time to change the way you work. For good. Our newest diagnostic and interventional imaging systems are designed around your specific workflow needs. For the latest Siemens has to offer in speed, simplicity, versatility, and diagnostic confidence. See for yourself at RSNA booth 7713, Hall B. www.siemens.com/medical

CC-Z1039-1-7600

What if workflow met innovation at every turn?

3Medical Solutions · December 2007 · www.siemens.com/medical-magazine

Editorial

Actively listening to you, our customers, and working together with you, be it onsite or at Siemens facilities worldwide, is key for us to understand your demands and to support you in achieving your goals. Quality of care, operational efficiency, and return on investment are among your most important topics. This was, for example, the feedback I recently received from my discussion with Professor Maximilian Reiser, Director of the Department for Clinical Radiology at the University Hospi-tal of Munich, during this year’s ISSSR*.

We are convinced that efficient workflow throughout the entire continuum of care, from early detection, diagnosis, and ther-apy, to follow-up, is one of the most rele-vant economic success factors in health-care in order to improve quality of care

Innovating Every Step of Your Workfl ow

Erich R. Reinhardt Member of the Managing Board of Siemens AG, President and CEO of Siemens Medical Solutions

and to achieve financial success. In this context, Healthcare IT solutions are essen-tial. This is illustrated, for example, by the recent introduction of Siemens Phar-macy and Med Administration Check at CentraState Healthcare System in the United States: Avoidable adverse drug events were reduced by 42 percent, while at the same time the medication docu-mentation was improved considerably, eliminating 90 percent of undocumented prescriptions and hence increasing charge capture significantly.

Accordingly, attaining superior workflow solutions is the most tangible asset for our customers to become successful. The required solutions reach beyond imaging systems and must cover the entire con-tinuum of care. So does our focus on the

implementation of our existing solutions and the development of solutions for the future. Our common goal is to optimize every step of the clinical and administra-tive processes in healthcare.

You can rely on Siemens to commit all its innovative power gathered during the past 160 years to this task in order to be your partner of choice in implementing workflow-optimized care. We invite you to join us on that journey.

Sincerely yours,

* 7th Radiology Symposium and Meeting of the International Society for Strategic Studies in Radiology

Medical Solutions · December 2007 · www.siemens.com/medical-magazine4

Content

Content

10 Innovation DevelopmentIn today’s healthcare environment, it is not enough to just develop innovative products – equipment suppliers have to consider clinical application, affordability, departmental workflows, training courses, ease of use, and many other aspects. Siemens takes this into account from early on in the product development phase all through market introduction. Medical Solutions talked to the heads of five Divi-sions about how the latest innovations came to being. And we spoke with futurist John Naisbitt about innovation and its adoption in the healthcare sector.

Cover Story

46Remote Solutions: Imaging and Viewing from Beyond

84Facility Planning: Patient and Personnel Needs

3 Editorial

6 News

99 Further Reading

101 Feedback

101 Trade Fairs

102 Imprint

103 Subscription


Content

58Image Management: Pediatric Cardiology

90 Virus Protection: Safety Net for Online Threats

78 Integrated RIS/PACS is a lever to increased efficiency, lower operational cost, and improved patient care.

84 When expanding and redesigning its Cancer Center, US-based Susquehanna Health focused on patient needs and workflow requirements.

90 Siemens protects hospitals’ imaging systems against viruses, worms, and Trojan horses.

96 Perioperative abdominal imaging heavily relies on precision and ease of use.

Features

25 Comprehensive solutions help streamline breast cancer manage-ment, from early detection to diagnosis, treatment, and follow-up.

36 A web-based electronic health record will link up all of German RHÖN-KLINIKUM AG’s 46 facilities to enhance the quality of care delivered to more than one million patients seen annually by the group.

40 In pursuit of business opportuni-ties, the private Swiss Sonnenhof Hospital is engaging in research for hip impingement arthritis.

46 Two solutions enable remote access to detailed 3D/4D information and allow system control from, for example, the office.

52 Leveraging on Siemens broad capabilities in healthcare and infra-structure and on Portugal’s hospital system reform, private healthcare operator Espírito Santo Saúde opened a completely digitized facility.

58 Two top children‘s hospitals in the US Midwest have optimized patient care by implementing digital imaging workflows and reporting in their car-diology departments.

66 A 20-minute magnetic resonance exam replaces several separate examinations in cancer staging and treatment planning.

70 New tools ease physicians‘ work for effective therapy control and follow-up of cancer.

Portable and Secure Access with the Patient Health Card

The patient health card is a secure means of storing vital patient data and is easy for the patient to carry.

Keeping Cardiac MRI Inline

With the new Siemens software module Inline Ventricular Function (Inline VF), physicians can accurately evaluate cardiac function immediately after magnetic resonance (MR) image acquisition. For the first time, the Siemens software enables fully automatic detection of heart contours and motion during image acquisition. Inline VF can also help improve workflow efficiency by enabling functional cardiac analysis to be performed even faster than before – right during image acquisition.There is no need to transfer the images to post-processing con-soles or manual postprocessing of contours. The heart is local-ized on MR images automatically; the system helps detect the inner and outer contours and generates the functional data

The Mount Sinai Medical Center in New York, USA, is currently issuing the Siemens Patient Health Card. The Patient Health Card is a secure and portable card designed to store patient demographic data and important healthcare information. Health-care providers can benefit from the tech-nology by using it to optimize clinical and administrative workflow. Patients benefit from secure and convenient access to their medical records.Much like a credit card, the technology is placed on a chip-embedded photo iden-tification card, which may contain patient information such as: medical history, chronic diseases, allergies, current medi-

cations, lab results, demographic data, and even insurance information. The patient must enter a personal identifica-tion number as the card is read in order to ensure data security. Insufficient access to patient information is a leading cause of medical error. According to the Insti-tute of Medicine at the National Academy of Sciences in Washington, DC, USA, as many as 98,000 people die in the USA each year due to preventable medical errors. The Siemens Patient Health Card allows patients to be tracked through the entire course of treatment and across organiza-tions, which may help to reduce errors and costs, and can improve healthcare quality.

without additional mouse clicks. The increased efficiency and diagnostic certainty with MR imaging will help even more patients to benefit from radiation-free cardiac examinations. Siemens has also developed Argus 4D VF for four-dimensional visualization of cardiac function. With this software, the physician can quickly analyze cardiac dysfunctions and run advanced 4D-volume imaging of the heart.The Inline VF software is available as part of the application syngo® BEAT, which not only helps improve workflow, but can also help in a variety of other ways, for example, to verify myo-cardial scars, to clarify thoracic pain (stress MRI), to evaluate congenital heart diseases, as well as to plan ablation in electro-physiology. MR images of cardiac functions, coronary vessels, and congenital heart defects can also be acquired three-dimen-sionally. The Inline VF software is available for 1.5 Tesla and 3 Tesla MAGNETOM® scanners.

Argus 4D VF allows left ventricular function assessment in less than a minute and provides advanced 4D visualization of the beating heart.

News


New Generation of the ARCADIS Family

The ARCADIS™ family of C-arm X-ray systems now helps customers and patients benefit from improved image quality and eased handling thanks to their new genera-tion of systems equipped with a brand-new ergonomic monitor trolley. With the latest advancements, health-care professionals can profit from improved clinical work-flow through user-friendly features and design. A broad range of applications and excellent image quality also remain important advantages.New features have been added to further help ease operation such as height-adjustable and rotatable monitors that allow for varying application-specific heights. They can even be folded during transport and storage. The reduced trolley weight and footprint help to ease maneuverability. New algorithms in subtraction, roadmaps for improved vessels and catheter visibility, and automatic dose and brightness adjustments lead to maximum image quality and user-friendliness.Cost-savings can be achieved with ARCADIS because it can be used throughout various clinical fields. With the Siemens syngo® user-interface, workflow can be enhanced via intuitive system operation, image post-processing, and networking. To help further optimize workflow, convenient ergonomic features have been added. Electromagnetic brakes also help ensure fast and precise positioning.

The new generation of ARCADIS C-arms brings various new features to aid in clinical workflow.

Patients admitted with acute chest pain to the emergency room (ER) of Alegent Health in Omaha, NE, USA, may very well proceed to treatment faster than elsewhere, even if their electrocardiograms, troponin, and other lab results are incon-clusive. Instead of continuous retesting for 24 hours, and possibly even a subsequent invasive exam if results are still unclear, such patients undergo an 82Rubidium-enhanced positron emission tomography-computed tomography (PET·CT) scan to evaluate perfusion of the myocardium, and receive their results within one hour. Samuel H. Mehr, MD, Alegent’s Director of Molecular Medicine and Imaging, says: “Studies* indicate that PET·CT perfusion testing in these patients has more than 90 percent accuracy, compared to other noninvasive or nuclear medicine exams.” Other than 18F-fluorodeoxyglucose for functional testing, 82Rubidium is readily available without labelling it in a cyclotron.In addition to faster treatment for patients whose chest pain is a symptom of coronary artery disease (CAD), quickly clari-fying which patients do not suffer from CAD is also beneficial – for both the patient, who doesn’t need diagnostic catheter-ization and can be released sooner, and the hospital, as it frees a bed, ER personnel, and the cath lab for other patients.According to Mehr, PET·CT myocardial perfusion testing can be particularly beneficial for young women in their 30s, who tend to have different symptoms when suffering from CAD – symptoms that even today rarely would lead to suspicion of coronary arteriosclerosis, like back pain and fatigue.

*Sampson et al., Diagnostic accuracy of rubidium-82 myocardial perfusion imaging with hybrid positron emission tomography/computed tomography in the detection of coronary artery disease, J Am Coll Cardiol. 2007 Mar 13;49(10):1052-8.

Diagnosing Faster, Safer

Dr. Samuel Mehr and the staff at Alegent Health benefit from the work-flow advantages provided by Siemens Biograph™ TruePoint™ PET·CT.

News

7

News

Redefining PET Imaging with High Definition

by HD·PET can literally change the whole picture. The added contrast is a result of the high-definition technology. Michael Reitermann, President of Molecular Imag-ing, Siemens Medical Solutions, adds, “The clarity of HD·PET will provide greater specificity and accuracy and will enable physicians to more confidently delineate small lesions – including those in lymph nodes, the abdomen, the head and neck, and the brain – to provide earlier, more targeted treatment.”By using a proprietary reconstruction technique, HD·PET provides distortion-free images throughout the entire field of view. Thanks to a two-millimeter reso-

In conjunction with the high-definition television trend that has transformed the entertainment world, Siemens has unveiled the world’s first high-definition position emission tomography (HD·PET) molecular imaging system. The revolution-ary HD·PET technology promises superior detection of small lesions with high defi-nition uniformity, resolution, contrast, and clarity. These advantages can aid in can-cer diagnosis, disease staging, treatment, and postsurgery/postradiation monitoring.Siemens Medical Solutions introduced HD·PET at the 2007 Society of Nuclear Medicine (SNM) Annual Meeting in Washington, DC, USA. The clarity achieved

lution, physicians can clearly distinguish even the tiniest of lesions. The clarity provided by high definition is invaluable in monitoring surgery or therapy patients. The improved delineation provided by the system can help physicians in terms of detection.HD·PET is available as part of Siemens TruePoint™ technologies – a unique com-bination of technological features and workflow solutions for PET·CT imaging to help better diagnose and treat patients. The high-definition feature will not only be available on all new Biograph™ TruePoint PET·CT systems, but also as an upgrade option for current Biograph TruePoint users.

Thanks to its two-millimeter resolution, HD·PET (left) allows for superior detection of small lesions, dramatically greater staging capabilities, and therapy accuracy, compared to conventional PET (right). Courtesy of University Hospital Erlangen, Germany


News

Large Improvements for Little PatientsAt the Department of Pediatric Radiology at the University of Heidelberg, Germany, Siemens Medical Solutions has teamed with physicians and technicians to provide solutions to improve the hospital’s efficiency and accuracy in its magnetic resonance imaging (MRI) processes. Especially in the field of pediatric radiology, it is important to keep in mind that children are not adults and have special needs when it comes to medical care. At the same time, increasing the quality of care and budget reduc-tions are also of concern for the hospital.A team of Siemens Healthcare consultants worked alongside representatives of the University of Heidelberg and came up with efficient and budget-friendly solutions for more than 100 chal-lenges that the hospital faced. A central goal was to decrease patient wait time by improving workflow processes. The patient throughput can also be increased thanks to a newly designed waiting room, created for patient preparation and recovery from examinations requiring sedation, which speeds the workflow process. Children often have to be mildly sedated before exams. Additionally, flexible office hours are now offered for working parents. In April of 2008, the Children’s Hospital at the University of Heidelberg will move into a new building. In the radiology department, a MAGNETOM® Avanto MRI system will replace previous imaging equipment. The solutions now in place in Heidelberg lead to a more efficient workflow despite budget restrictions – solutions that not only benefit the patients, but the staff as well.

Siemens Automation and Drives (A&D) has developed a new five-megapixel monochrome display, the SMD 21510 D, ideally suited for mammography diagnosis and picture archiving and communication systems (PACS). With excellent image quality, this integrated Fully Automated Stability system provides reli-able gray-scale response and continuous luminance levels. The display can also be used with the latest standard, high-perfor-mance graphic cards.The 21-inch high-resolution monitor is equipped with two independently functional sensors that are used to continuously monitor the luminance and grayscale levels. An Integrated Stability Sensor (ISS) monitors the backlight in the center of the display, and the Integrated Consistency Sensor (ICS) monitors performance on the front right corner without obstructing the view of the display. This monitoring system provides high image quality and conforms to medical imaging standards such as DICOM (Digital Imaging and Communications in Medicine). The Cold Cathode Fluoroescent Lamt (CCFL) backlight is optimally suited for the human visual system which is especially sensitive

Versatile New Monitor

to lights in this color range. The SMD 21520 D display comes precalibrated and is ready for use immediately out of the box, a feature available with all Siemens medical displays. For quick and easy installation, the monitor has five preset 12-bit Look-up Tables (LUTs), which allow for adaptations to any lighting envi-ronment. The monitor data are stored in the LUTs, which also makes it compatible with almost any graphic card. The specific SMD 21510 D settings can be tailored to the local environment, the luminance values can be measured, and the internal sensors can be readjusted to their optimal levels when necessary.

The new monitor provides reliable gray-scale images and can continuously monitor

luminance levels.

The University Hospital works to improve patient throughput without jeopardizing quality care or budget concerns.

Medical Solutions · December 2007 · www.siemens.com/medical-magazine 9

Innovations

At this year’s Radiological Society of North America Annual Meeting, Siemens introduces its latest crop of new and exciting products. All are designed to fi ll the needs of customers in today’s climate of rapid technological change and workfl ow improvements, and are adaptable to serve them well into the future.

By Haig Simonian

Innovating Every Workflow Step

To say that innovation is an essential part of Siemens seems like stating the obvious. This, after all, is the company that intro-duced the world’s first X-ray tube, the first commercially available ultrasound system with real-time display, the first instant image generated by computed tomogra-phy (CT), and the first common user inter-face across imaging modalities, syngo®.But innovation today means much more than fancy products with long names. As busy physicians and technicians know all too well, ’new‘ is no longer enough. Stretched budgets – whether from public-sector healthcare providers or private-sector reimbursement schemes – mean a new diagnostic or therapeutic tool has to offer real advances in terms of reducing costs or improving quality of care, and ideally both.“Innovation for me means something that offers a significant improvement for my customers. Even though improved patient care is still the primary criterion, financial benefits from these innovations are also getting more and more important,” says Norbert Gaus, Head of the Angiographic, Radiographic and Fluoroscopic (AX) Divi-sion at Siemens Medical Solutions. “We support our customers by specifically developing products and solutions that increase the quality of healthcare and preferably simultaneously lower its cost.”Take the new Artis™ zee family featuring Artis zeego* from Gaus’ own Division. Designed for a wide range of interven-

tional procedures, the family offers not only patently better image quality, but also significantly enhanced operability for physicians and technicians, saving both time and money. Siemens philosophy when developing the Artis zee family was to help customers to see more, so they can do more – because only excellent image quality helps them to make better treatment decisions and improve patient care. The company wants their customers to be at the forefront of technology and get the most from their interventional suite. They are achieving this goal by pro-viding systems with excellent imaging capabilities and enhanced workflow improvements, so customers can invest with confidence.Such advances are critical – and potentially lifesaving – in the intricate heart, brain or abdominal procedures, among others, for which the new equipment has been designed. “We can acquire high-quality, cross-sectional images in the interven-tional suite,” explains Gaus, an electrical engineer who has spent much of his career in research, especially in information tech-nology. Artis zeego* is the first multiaxis system that can be positioned exactly the way it is needed, and controlled with far greater ease and precision than any tradi-tional floor- or ceiling-mounted system, he says. “It provides greater positioning flexibility and broader coverage, including large volume cross-sectional imaging.”“If you have clarity after ten minutes, you

maybe save a life, and you certainly save cost,” agrees Bernd Montag, speaking of the improvements in the products being unveiled by the Computed Tomography (CT) Division he runs. Montag highlights the new adaptive scanner (AS) version of his Division’s SOMATOM® Definition era system, a 2007 RSNA debut building on the breakthroughs of the first SOMATOM Definition product two years ago.“This is the world’s first adaptive scanner. It can be matched to any patient, includ-ing those who might have been difficult to scan before. This is what I call the tran-sition from ‘almost’ to ‘always,’” says Mon-tag, describing the system’s significantly enhanced flexibility. SOMATOM Definition AS** also allows radiologists to be much more specific in their judgments, thanks to exceptional clarity. Moreover, adds Montag, with the ability to produce up to 128 slices per rotation with down to 0.24 millimeter resolution – far more than any previous system – it can create a virtual three-dimensional copy of a patient.

Customer Input Drives Improvements

But it is not just one or two Divisions of Siemens Medical Solutions that will share

** The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the USA.

** Status at editorial deadline: The information about this product is being provided for planning purposes. The product is pending 510(k) review and is not yet commercially available in the USA.


Innovations


Artis zee: An Entirely New Family for Interventional Imaging

With Artis™ zee, Siemens Medical Solutions launches a completely new family that provides high-end imaging for interventional suites in radiology and cardiology. The versatile systems offer excellent image quality, enhanced speed and workflow, as well as improved ease of use, which also makes them suitable for the operating room (OR). A highlight of the new Artis zee family is Artis zeego*, the first multiaxis system that can be controlled with far greater ease and precision than any traditional floor- or ceiling-mounted system. It offers many possibilities.Installed in an interventional lab, the system provides excellent 3D imaging including Large Volume syngo DynaCT* and improved stent visibility with IC Stent*. Installed in an OR environment, Artis zeego is readily available when required, but easily stows away when not needed, giving the surgical team all the access it needs for pure surgical procedures, such as anesthesia, while at the same time it leaves the ceiling free for laminar airflows, lighting, and other installations. The great flexibility of the multi-

axis stand allows the OR to be used for both surgical and endo-vascular or cardiovascular procedures. During emergency situa-tions, the surgeon can directly start with open surgery without wasting valuable time to transfer the patient to the OR. Thanks to its flexible working height, it also helps prevent back pain and fatigue in the surgical team.The great flexibility of the whole Artis zee family for angiography and cardiology suggests some changes in the clinical processes to improve financial benefits as well. For example, hospitals could move interventional needle procedures to the angio suite, utilizing syngo iGuide to provide planning for live and integrated needle guidance. This would free the computed tomography (CT) system for better reimbursed diagnostic examinations. syngo DynaCT offers cross-sectional imaging in the interventional suite and provides easy navigation and control during procedures like chemoembolization or radiofrequency ablations.

the limelight at RSNA. Over at Magnetic Resonance (MR), the Division is unveiling a pair of groundbreaking – and surprisingly complementary – newcomers.MAGNETOM® Verio promises to combine Siemens best performance levels in a novel format that should be noticeably more patient-friendly, while also improving work-flow for staff. It is the most exciting equa-tion in MRI: three Tesla field strength plus 70 centimeter Open Bore, plus Tim® (Total imaging matrix) technology. Adding ten centimeters of width to the bore may not sound like much to the layman, admits Walter Märzendorfer, Head of the MR Divi-sion. “But offering a first-ever, 70-centi-meter bore while maintaining 3 Tesla field strength will make a massive difference for

patients who have felt uneasy about the restricted space available in the past,” he says. “We’ve also managed to build the shortest 3 Tesla system on the market today. That means patients can have a good experience during the examination. And noise levels are optimized thanks to intense work by our researchers on the system.”Märzendorfer, who formerly led develop-ment in CT, is justly proud of his new product. But he also understands that not every hospital or practice will have the financial resources to afford such equip-ment. So MR is also unveiling what he calls a “value product” in the form of the new MAGNETOM ESSENZA scanner, designed for smaller hospitals and prac-

“ We support our cus-tomers by specifi cally developing products and solutions that increase the quality of healthcare and prefer-ably simultaneously lower its cost.”

Norbert Gaus, President, Angiographic, Radiographic and Fluoroscopic Division, Siemens Medical Solutions, Forchheim, Germany

* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the USA.

* The information about this product is being provided for planning purposes.The product is pending 510(k) review, and is not yet commercially available in the USA.

Innovations


Norbert Gaus Head of the Angiographic, Radiographic and Fluoroscopic Division at Siemens Medical Solutions

tices that want to take advantage of the opportunities offered by MR, but at a more affordable price.“This system will make MR imaging attain-able for many hospitals and practices that simply can’t run it today. MAGNETOM ESSENZA represents a paradigm shift. It could change the market,” Märzendorfer predicts. The key lies in the fact that Siemens put many innovations together,

including Tim, that allow combining excel-lent performance with a patient-friendly design, “in a package really optimized for total cost of ownership,” he says. “We know there is enormous cost pressure on our customers, so we’ve got to find ways to make MR more affordable for new users.”Whether in AX, CT, MR or other key Divi-sions, all new Siemens products reflect intense interaction between the company’s

research and development and marke-ting staff with key customers. For Klaus Hambüchen, Head of the Ultrasound (US) Division, such interaction starts well before the first ideas reach the drawing board. At his headquarters in Mountain View, CA, USA, Hambüchen and his teams invite about 100 ultrasound power users and key customers a year to visit the Siemens Ultrasound Innovation Center

Innovations


“We want to optimize everything from how you conduct an exami-nation to distributing the data to provide the highest image quality and the maximum throughput.”

Jochen Dick, President, Special Systems Division, Siemens Medical Solutions, Erlangen, Germany

MAMMOMAT Inspiration: Increasing Mammography Acceptance

With MAMMOMAT® Inspiration*, Siemens is developing a product platform for mam-mography with the goal to combine techni-cal innovation and patient-centered design. In its different configurations, MAMMOMAT Inspiration shall address the needs of a screening environment and additionally provide easy upgradeability to diagnostic mammography and stereotactic biopsy. It is planned with high throughput and work-flow efficiency for screening as well as excellent image quality at low dose in mind. An equally important aspect in its develop-ment is patient well-being and thereby increasing the acceptance of the screening process. Backlit MoodLight™** panels are planned to support MAMMOMAT Inspira-tion providing a mammography environ-ment with the aim to help alleviate patients’ fears and improve the diagnostic center’s image. In addition, it shall represent a tech-nology platform that opens customers a smooth upgrade pathway from today’s configuration to future three-dimensional mammography with tomosynthesis*.

and discuss how the Division’s products can be further improved.“This is where we gain a lot of direction and perspective about the clinical priori-ties,” says Hambüchen, a long-time Siemens executive who has spent virtually his entire career in different Divisions at Siemens Medical Solutions. “Such contacts are especially important in the early phase.” The filtering process from initial idea to eventual innovation is relentless – and sometimes ruthless. “You cannot assume that every concept, no matter how prom-ising, will result in a product,” he explains. “We consider it a success if out of every ten early-stage ideas, three survive into further development.”Hambüchen argues that the sheer variety of ultrasound, with applications from general imaging, gynecology, urology, obstetrics to cardiovascular imaging, makes customer feedback particularly important. “Ultrasound covers the widest range of applications,” he says. “Compared to other

imaging modalities, however, true inno-vation in ultrasound has been slow over the last ten years. This is why we’re focus-ing on reestablishing ultrasound’s cre-dentials by introducing a new generation ultrasound platform that will be offering unprecedented customer demand fulfill-ment.“ The ACUSON S-Class, making its debut at RSNA, breaks new ground in the specificity of ultrasound with the introduc-tion of Acoustic Radiation Force Impulse (ARFI) imaging. ARFI exploits differences in the mechanical properties of soft tissue to delineate tissue structure that is not necessarily apparent with conventional B-Mode ultrasound. This technology has the potential to differentiate, for example, tumors from healthy tissue. Says Ham-büchen: “Our customers and their passion for workflow improvements helped us to achieve this goal.”“In the past five to ten years, there have been some dramatic changes,” adds Montag of CT. “We have gone from being

** CAUTION: Investigational Device. Limited by U.S. Federal law to investigational use. This product is not commercially available in the United States (USA). The information about the MAMMOMAT Inspiration is being provided for planning purposes. The product must be reviewed via the FDA PMA review process and its future availability cannot be ensured.

** Planned to be an option.

Innovations


a very technology-focused company to one driven by the exciting interplay between technology and customer requirements.”

Emphasis on User-Friendly Products

The demand on making new equipment easier to use is another reflection of that mentality. It has also been at the center

Jochen DickHead of Special Systems Division at Siemens Medical Solutions

for the design of the Acuson S-Class. “The new S-Class anticipates the fusion of a Porsche performance with the comfort of a Mercedes Benz,” says Hambüchen of Ultrasound. With these specifications in mind, the engineers designed an ergo-nomic and tactile user interface as well as auto-navigating software.Jochen Dick, Head of Special Systems (SP) Division, uses the phrase “one-click tech-

nology” to describe what his research and development teams and designers want to accomplish when thinking about ease of use. The MAMMOMAT® Inspiration digital mammography system, currently being developed, is planned to be the SP Division’s first such product to be con-ceived from the start for the digital era, with its design brief focusing on stream-lining throughput while maintaining

Innovations


ACUSON S-Class: Acoustic Mastery

The ACUSON S2000™ ultrasound system is the first product of the new Siemens next-generation ultra-sound platforms, the S-Class. With roots in Siemens leading image quality and workflow advancements, the S-Class drives efficiency and specificity in clinical procedures. Workflow and new applications expand its clinical utilization.The S-Class will feature a combination of new clinical applications such as Automated Breast Scanning (ABS)*, Knowledge-based Imaging, Isotropic Volume Imaging, Molecular Contrast Ultrasound and ARFI (Acoustic Radiation Force Imaging), extending diag-nostic capabilities and outcome beyond the tradi-tional roles of ultrasound. In addition, the ACUSON S-Class next-generation ultrasound systems are Sili-con Ultrasound enabled, making them ready for true isotropic volume imaging, previously the domain of magnetic resonance imaging (MRI) and computed to-mography (CT).With their compact ErgoDynamic™ system design, optimized control panel, and logical, intuitive user interface, the ACUSON S-Class systems will set a new industry benchmark for clinical workflow ergonomics.

“Customer contact is where we gain a lot of direction and perspective about the clinical priorities.”

Klaus Hambüchen, President, Ultrasound Division, Mountain View, CA, USA

image quality. “Take a high-volume screen-ing environment, such as breast scanning,” says Dick. “You have a lot of patients, many of them nervous. So for the patient, the whole procedure must be as quick and palatable as possible. For the clinic, on the other hand, speed, efficiency, and accuracy are of the essence.”Dick’s “one-click technology” means sim-plifying procedures to raise throughput to 15 patients an hour. The new MAMMOMAT Inspiration is being designed accordingly to accelerate everything from initial patient positioning to selecting the right patient data and then transferring it to the central database. “We want to optimize every-thing from how you conduct an examina-tion to distributing the data to provide the highest image quality and the maximum throughput,” he says.Siemens concentrated on user interfaces early on and, already in 1999, introduced the first syngo-speaking CT scanner. Today, all Siemens imaging modalities ‘speak’ syngo, thus making the transition to a new system a seamless process for technicians and physicians alike. The new Siemens

products also include features to harness the latest leaps in information technology and data communications. In CT, for example, the new SOMATOM Definition series allows data to be accessed through a Web interface, rather than – as in the past – exclusively via complex hospital workstations. That means that a physi-cian can see relevant patient information whether he or she is working in a practice or even from home. “The whole idea has been to optimize the workflow to allow all those authorized immediate access to the data. These are the guiding principles of our high-end CT range,” explains Montag.The Siemens executives recognize that stress on improving workflow reflects the concerns of customers who are facing ever-increasing financial pressures. Dick, for example, notes how important it is for SP Division customers – such as those involved in high-volume screening – to calculate the cost of equipment against patient volumes and reimbursement rates before authorizing any spending, no mat-ter how great the quality improvements. “Take mammography,” he says. “Invest-

* The information about this product is preliminary. The product is under develop-ment and not commercially available in the USA, and its future availability cannot be ensured.

Innovations


Klaus HambüchenHead of the Ultrasound Division at Siemens Medical Solutions

ment decisions are highly influenced by quality and patient friendliness. But work-flow is the most significant differentiator in our field.”Helping customers make the right invest-ment decisions is central to what Siemens can offer; irrespective of whether X-ray, computed tomography, magnetic reso-nance or ultrasound is concerned. “Obvi-ously, every setting is different,” says Dick.

“The country, precise location, through-put, and reimbursement regime are all decisive. But working with our country specialists and sales staff, we have learned to create immensely detailed models. We start with the number of patients likely to be handled, then add variables such as the mix between screenings and, say, diagnostic work. Reimbursement regimes for different procedures are also critical;

so are staff numbers and salary costs, as well as space requirements and property rental prices. In the end, we can produce a realistic package tailored individually to each customer.” Such modelling may seem more appropriate for smaller private prac-tices or physicians’ partnerships than for massive teaching hospitals, but Märzen-dorfer of MR says it is just as relevant for large departments acquiring multimillion

Innovations


SOMATOM® Definition AS* is the first single source computed tomography (CT) system to truly break through the barriers of conventional CT. It intelligently adapts on the fly to a patient, physician, and the clin-ical task. Innovating by modifying every component of multislice CT, SOMATOM Definition AS is the only CT to adapt to any patient, transforming into an expert in any field, at the command of the radiologist. This CT system actively manages dose in 100 percent of all exams. Its Adaptive Dose Shield dynamically removes clinically irrelevant dose. With its unique Adaptive 4D Spiral, SOMATOM Definition AS moves beyond fixed detector limitations to provide full coverage of any organ in 4D. In stroke or tumor assessment, this gives invaluable functional information. Additionally, with its built-in 3D minimally invasive suite, the system makes routine and complex procedures easier. SOMATOM Definition AS adds precision while reducing proce-dure time.

SOMATOM Definition AS: Adapting CT to Clinical Needs

“The whole idea has been to optimize the workflow. If you have clarity after ten minutes, you maybe save a life, and you certainly save costs.”

Bernd Montag, President, Computed Tomography Division, Siemens Medical Solutions, Forchheim, Germany

dollar systems as individual practices seek-ing more modest tools. “Large hospitals or, depending on the healthcare system, entrepreneurial private practices are key customers for us. But even dealing with such large units, we place immense im-portance on each individual customer’s needs,” he says. “That can start with help on planning everything from the posi-tioning of our equipment to training staff. Adding value and quality while improving efficiency are our watchwords.”

A Balance between Evolution and Revolution

With efficiency and productivity so crucial, reliability is paramount. All of the Siemens executives speak proudly of the Guardian Program™, a plan offering not only turn-key maintenance but even, where techno-logically possible, real-time fault preven-tion.Dick of SP explains: “If there is an issue, instead of sending out an engineer, we can tackle it from one of our Regional Support Centers. In many cases, especially

with software, they can be fixed remotely. Moreover, with proactive monitoring, systems are constantly checking up on themselves. If something’s amiss, we auto-matically receive an alert and can often take action before use becomes limited. You can imagine what an out-of-action system means for a customer handling 100 patients a day!”Deciding whether to sign up for the Guardian Program is, of course, up to each customer. But the package is sufficiently flexible for it to be selected even after the sale. “Guardian can be built in from the start. But we also have customers who prefer to wait until after warranty,” notes Märzendorfer of MR. “None of our com-petitors have anything like it,” adds Gaus of AX.“With the Utilization Management service, we can even offer benchmarking, allow-ing customers to see how they are per-forming compared with others in similar settings. That can help them fine-tune their procedures in case there is room for improvement,” notes Märzendorfer. While the new Siemens systems represent the

* Status at editorial deadline: The information about this product is being provided for planning purposes. The product is pending 510(k) review and is not yet commercially available in the USA.

Innovations


Bernd MontagHead of the Computed Tomography Division at Siemens Medical Solutions

pinnacle of today’s technology and prom-ise impressive reliability, physicians are among the first to admit that scientific progress is relentless. So the issues of allowing for technological updates and – eventually – of dealing with obsolescence, are prominent on their agenda. With new technology releasing ever greater volumes of data, for example, fears of flooding a

hospital’s picture archiving and commu-nications system (PACS) with every new generation of equipment is an often-mentioned concern.Executives from Siemens Medical Solutions believe they have found a reasonable balance between evolution and revolution. “To keep our customers on top of software and hardware upgrades and updates, and

to extend their systems’ life cycles, our customer care solution, Life, offers pack-ages and service contracts to help them benefit from the latest workflow improve-ments, clinical applications, and diagnos-tic functions,” says Gaus of AX.Building in flexibility to allow technologi-cal updating is a prime design criterion. “Whether software or hardware, when we

Innovations


MAGNETOM Verio: The Most Exciting Equation in MR Imaging

On the ultra-high field side, Siemens introduces MAGNETOM® Verio, the world’s first 3 Tesla magnetic resonance (MR) system with a 70-centimeter gantry opening. Siemens is the only vendor to offer 70-centimeter Open Bore technology at 1.5 Tesla and now even introduces it at 3 Tesla, allowing for more patient comfort, better workflow and reduced costs in high-end MR imaging for the diagnosis of challenging diseases. MAGNETOM Verio comes with Tim® (Total imaging matrix) technology for fast and easy coil setup and reduced acquisi-tion times, T-class for shorter order-to-report turnaround time and seamless workflow, and I-class advanced applications. Its 70-centimeter Open Bore enables better patient comfort and thereby improves workflow and outcomes in the MRI suite: Fewer claustrophobic or pediatric patients need to be sedated; bariatric patients can be examined without triage; patients in pain can be positioned more flexibly; less anxiety-related movements lead to better image quality; patient access is improved for both intensive-care patients and MRI-guided interventional procedures; and kinematic studies can be performed.

MAGNETOM ESSENZA: The New Business Partner in MR Imaging

Customer demand for a low-cost and high-quality magnetic resonance (MR) scanner led to the development of MAGNETOM® ESSENZA. Siemens used its innovation power to design an af-fordable* all-new 1.5 Tesla system that also offers the bene-fits of the latest Siemens MR technology, with its clinical ap-plications and high throughput, to customers with lower budgets who want to enter the realm of MR imaging. The sys-tem was developed from the ground up to be an affordable, reliable powerhouse, and is packed with innovations to sup-port both clinical and financial success. These innovations in-clude a brand-new, ultra-light, small footprint 1.5 Tesla mag-net, Siemens-unique Tim® (Total imaging matrix) technology for easy coil set-up and reduced examination times, as well as workflow automation tools based on Siemens unique syngo® user interface. With these innovations, it’s not just the pur-chasing price that makes the system affordable, but also its low installation and operating costs and workflow advantag-es, which all join forces to maximize revenue.

“Whether software or hardware, when we make changes, we try to ensure everybody has a migration path to the next level.”

Walter Märzendorfer, President, Magnetic Resonance Division, Siemens Medical Solutions, Erlangen, Germany

make changes, we try to ensure everybody has a migration path to the next level,” explains Märzendorfer. “We put a lot of effort into making sure that customers who invested in our solutions can also profit from the latest developments.” Modular design plays an important part in sup-porting this effort. Märzendorfer draws attention to his Division’s Tim technology,

* Results may vary. Data on file.

Innovations


Walter Märzendorfer Head of the Magnetic Resonance Division at Siemens Medical Solutions

Further Information

www.siemens.com/rsnawww.siemens.com/AXIOM-RSNA-2007www.siemens.com/SOMATOM-RSNA-2007Haig Simonian is the Switzerland and Austria

correspondent for the Financial Times.

which provides the ability to upgrade MRI systems dating back as much as ten years. “A significant amount of what we do involves working with research insti-tutes, and modularity is very important for them; eventually, that feeds back into the product pipelines,” he says.Such sentiments are echoed by all of his colleagues. Whether AX, CT, MR, SP, or

US, keeping customers at the forefront is the parameter that characterizes all of the outstanding new equipment being unveiled at RSNA this year.

Naisbitt‘s first book, Megatrends, published in 1982, has appeared in 57 countries and sold more than nine million copies. Since then, Naisbitt has gone on to write works about global trends, advising companies and governments along the way. His cur-rent focus is on Asia, particularly China, where he is spending increasing amounts of time.

Mr. Naisbitt, thank you for finding time to talk to us. How do you under-stand the word ’innovation‘?NAISBITT: I associate it with the evolution-ary development of technical knowledge. I don’t think there will be a ’next big thing,‘ as the media sometimes suggests. That’s just hype. We’re deeply into an evolution-ary era, similar to the one in the 20th cen-tury.Looking, as I do, at all the timelines cov-ering very many years, it appears that great breakthroughs – and certainly tech-nological ones – come in clusters. We get these clusters, and then we spend a very long time extending and perfecting what we’ve discovered during them.Take the end of the 19th century and the start of the 20th century as an example, with the invention of the telephone, the automobile, the airplane, and electricity. Then we spent the whole of the 20th century extending and perfecting them. We’re still working on the airplane; we’re still working on all of them.

What’s in the latest ’cluster‘?NAISBITT: At the start of the present century, it’s been information technology, biotechnology, and nanotechnology. We’re going to spend most of the 21st century evolving what we’re discovering now. It’s just beginning. We’re on the edge of so many things. Even with IT: The Internet was a great breakthrough, but it’s still primitive. I think 40 years from now, we’ll look back and say it was primitive. Like-wise in biotechnology.

Has the concept of innovation changed over time?NAISBITT: Obviously, the idea of ’new‘ is invariably bound to innovation. But it hasn’t always been linked to what I’d call ’hard‘ developments. How innovative was the language and construction of James Joyce’s Finnegan’s Wake? Or certain struc-tures in poetry? But certainly, we’re now in a technological era, and that’s a great reservoir for innovation.Change is the key concept here. When things change, you get new relationships, creating new possibilities. But while they change, most things remain constant – take family, work, religion, education, even sport. So those people in business who say change is our only constant: nonsense.

Has innovation always meant the same for all peoples or cultures over time?

NAISBITT: The meaning of the word has been the same for a long time. But you have to probe beneath the surface. Take ancient China. They invented so many things: gunpowder, moveable type, and the origins of the compass. But they never did the development; they never moved on to the essential evolution of those breakthroughs. Just look at today’s Apple® iPhone™. It’s nothing really new, but what’s striking about it is that it has put three existing technologies together. That perfectly illustrates the evolutionary era we’re in. And, turning back to the Chinese, I can tell you: The new China has got the idea now.

Let’s turn to business. For companies, is innovation the key competitive factor?NAISBITT: There’s a very good reason why today’s mantra in business is growth through innovation. It’s because we’re in a period of evolution, full of opportunities and chances to enhance what’s been done before.It’s the innovative companies that are going to have the edge over their rivals. But just discovering something isn’t enough. It’s the skill to be able to refine, enhance, and apply that will count.So it’s about more than technology. Most people think about innovation in a purely product context, but innovation is as important in services as in products. Many companies are struggling with perfecting

“Discovery isn’t Enough”

John Naisbitt, an American who has lived in Europe for the past eight years, is one of the world’s most renowned futurists. Medical Solutions interviewed him at his apartment in Vienna, Austria.

By Haig Simonian

Innovations


the innovation, for example, of online orders and reservations. The airlines are really struggling with this, but no one’s got it quite right yet. We tend to forget that innovation in service is as important as purely technological product break-throughs.

Are medicine and medical technology any different?NAISBITT: At the beginning of the 21st century, at a forum on what had been the most important breakthroughs of the previous hundred years, most people identified the ’hard‘ technologies – literally hard, like airplanes. In medicine too, there have been some outstanding develop-ments. One of the most extraordinary, to my mind, has been prosthetics, and, specifically, artificial limbs.The very fact that science has come up with artificial legs that might allow handi-capped athletes to run in races is extra-ordinary. Even more extraordinary, some competitors are already claiming that will provide an unfair advantage. What a tribute to science! But I would say the

most important developments have come from what I describe as ’soft‘ technology – namely, the development of antibiotics. Since the middle of the 20th century, anti-biotics have prolonged the lives of un-counted millions, from the great to ordi-nary people in the street. In medicine, most of the businesses involved are what I would describe as ’hard.‘ However, I think it may be the ’softer‘ technologies, especially biotech, that will provide the most conse-quential developments of the 21st century and beyond.

Why is that?NAISBITT: Because the development of what we already know will result in the human race being in charge of its own evolution. The same genetic technology that will allow us to cure and eliminate such terrible diseases as Alzheimer’s or Parkinson’s also allows us to have progeny that are taller, smarter, faster, more beau-tiful or whatever, and no one is talking about it.

So not all innovations are good?

This touches on the question of our rela-tion to technology. It’s a question of what I call the ’ecology‘ of technology. In nature, when things in a habitat change, like the introduction of a new species or a shifting climate, it changes the relationship with-in the habitat, but human beings unques-tioningly introduce new technologies into their own habitat.Whenever a new technology is introduced into our lives, it seems to me we should ask some questions. For example: By doing so, what would be enhanced? What would be diminished? And what would be re-placed? Our relation to technology is the most unexamined relationship we have.

Are you at all confident that we’re starting to ask such questions?NAISBITT: No, I’m not. We’ve left it to the marketplace to sort matters out. But I think we ought to take greater charge of our own destiny. Our salvation is that things we expect to happen always hap-pen more slowly than we imagine. It is the surprises, like AIDS or 9/11, that over-whelm us.

John Naisbitt (left) with author Haig Simonian (right)

Innovations



The Next Wave in Breast Cancer Management

Around the world, breast cancer management is changing radically. International medical experts link the corresponding decline in breast cancer

deaths to earlier detection and advanced treatment options.

By Laura Newman

Breast Cancer


Herself a one-time patient at Battlefield Auxiliary Breast Center, Barbara Robertson (standing left on top left photo) sees patients through their breast cancer journey. Modern Siemens equipment supports care – from mammography to ultrasound (top right), MRI (bottom left), biopsies (bottom right), and PET·CT (previous page).

Breast Cancer


The radiology suite is moving towards a completely digitized environment, with the best offering integrated imaging sys-tems that span the clinical, operational, and financial workflow. Siemens now has more than ten innovative breast imaging and treatment solutions for improved diagnosis, better localization of lesions, targeted treatment, and long-term moni-toring. The following article takes a com-prehensive look at current innovations and new developments on the horizon.

Leading the Fight

Barbara Robertson finally got her diagnosis of breast cancer in 2004. Her story shows why her diagnosis was delayed until she underwent breast magnetic resonance imaging (MRI) with Siemens Open Bore MRI scanner MAGNETOM® Espree.In 1999, when she felt pain in her stom-ach and had difficulty eating, Robertson sought medical help. She was told that she had inoperable stomach cancer and that she had between four and six months to live. At that time, she was 64 years of age. She chose no chemotherapy, no radi-ation, and no surgery. Fortunately, her daughter was in the medical field and together, they sought a second opinion.Eventually, Robertson learned that breast cancer can mimic stomach cancer, and that her primary tumor was in the breast. “The breast cancer was not seen on mam-mography or ultrasound,” she explains. “It was only seen on MRI.” In the time since her first diagnosis, her tumor had spread beyond the stomach, to the bones, and recently, to the bladder.It is possible that, had today’s compre-hensive imaging solutions such as breast MRI been available earlier, Robertson’s breast cancer might have been detected sooner, when it was more curable and less likely to spread. With today’s technol-ogy, the door might have swung open to more effective treatment for her.Siemens MAMMOMAT® NovationDR full-field digital mammography machine is more accurate than analog machines in dense breasts, premenopausal and women under 50, and it also delivers only half the radiation. Therefore, it enables better detection of breast cancers in these patients during initial evaluation or annual mammograms*. In addition, today’s ultra-

sound Elasticity Imaging can be effective after an unclear mammogram and conven-tional ultrasound. Lately, Elasticity Imaging has emerged as a sensitive and accurate method that more clearly demonstrates relative tissue stiffness or hardness.

Arriving at the Right Diagnosis

Robertson received her accurate diagnosis at Battlefield Auxiliary Breast Center in Ringgold, GA, USA. When Battlefield asked for volunteers to undergo breast MRI, more than 200 women responded. Robertson gladly became the first case. “It was only with this breast MRI that my breast can-cer was picked up,” she says. “You can’t imagine how well they treat people here – the staff is so nice and courteous – and what a good feeling it is to know that you are being diagnosed with the most current tests.” Robertson says she feels indebted to the center for her excellent care and volunteers there two days a week. At age 72, she reflects on her experience: “I think that this is my calling – to be right here at Battlefield and support women as they go through their journey. As long as I can keep doing it, I am going to do it.” Battlefield’s Director, Barbara Marshall, RT, in turn, says the center is indebted to Robertson: “She gives her heart and soul to this place.”Battlefield Auxiliary Breast Center is part of Hutcheson Medical Center. It opened its doors in 2004. John F. Nelson, MD, the center’s Medical Director, describes it as a “bread-and-butter community imaging center.” He says it was five years in the making, and has now been three years in operation. Breast cancer survivors helped design the space and its patient amenities at Battlefield. Dedicating a separate space for women’s health imaging away from the rest of the center offers women the privacy they need. Placing all breast imag-ing services under one roof, with each modality housed in close proximity, has made it easy for patients to navigate from one test to another. Center staff and vol-unteers are proud of their comfortable waiting rooms, relaxed and private areas to discuss results, and the fact that they provide patients with nontraditional, pat-terned robes during their visit – which, thanks to the efficient Siemens equipment, is usually brief.Located in the northeastern corner of Georgia, it was the first center in the tri-

“You can’t imagine how well they treat people here and what a good feeling it is to know that you are being diag-nosed with the most current tests.”

Barbara Robertson, Patient and Volunteer, Battlefield Auxiliary Breast Center, Ringgold, GA, USA

* Pisano et al., Diagnostic Performance of Digital versus Film Mam-mography for Breast-Cancer Screening, N Engl J Med. 2005;353.

Breast Cancer

“The time that we are able to dedicate

to patient care is greatly owed to the fast and easy work-

fl ow at the systems themselves as well

as when reading images and dictat-

ing results.”

John F. Nelson, MD, Medical Director, Battlefield Imaging, Ringgold, GA, USA

state (Georgia, Tennessee, South Carolina) area to offer full-field digital mammogra-phy and to embrace digitized imaging. Center Director Marshall credits a strong collaboration with Siemens as enabling Battlefield to stay out front. “They have always been supportive, and we have a mutually beneficial arrangement,” she says. Owning MAMMOMAT Novation has proved an important marketing tool, according to Nelson. “Women realize that this is an up-to-date and accurate mammography system, and they no longer have to drive to Chatta-nooga [Tennessee] or Atlanta [Georgia].” The availability of cutting-edge imaging and tender loving care has also attracted

women throughout the tri-state area, as well as Alabama, he adds. “Everybody comes here – mothers, grandmothers, daughters.” Both Nelson and Marshall credit a solid collaboration with Siemens and their excellent staff – including a large number of volunteers like Barbara Robertson – for making the facility a leader in breast care.Nelson realizes that offering a panoply of the latest imaging modalities is crucial for optimizing screening, diagnosis and staging, treatment, and monitoring. It is also essential for Battlefield’s continued success. Center administrators are proud to be the first community center in their area to have the MAGNETOM Espree Open

Offering a panoply of the latest imaging modalities is crucial for optimizing breast cancer care, according to Dr. Nelson.

Bore MRI system with Tim® (Total imaging matrix) technology. Other equipment includes a syngo® Opdima upright stereo-tactic biopsy system, an ACUSON Sequoia™ ultrasound system, and a Biograph™ TruePoint™ PET·CT (positron emission tomography-computed tomography) scan-ner. According to Nelson, use of the MRI scanner has soared so much that the cen-ter is adding another Siemens system, the brand-new MAGNETOM ESSENZA, where Battlefield continues to be an early adopter of state-of-the art technology. He fore-sees an expanding role for breast MRI in the context of evaluating women who are premenopausal, have dense breasts, have a strong family history of breast cancer,


Breast Cancer

“We have a vision – taking women through the journey

from discovery to recovery, touching one life at a time.”

Barbara Marshall, RT, Director, Battlefield Imaging, Ringgold, GA, USA

For Barbara Marshall, excellent staff, including a large number of volunteers, is key to providing patient-centered care.

and are among those who test positive for the BRCA1/BRCA2 gene mutations.

Accelerated Workfl ow

Battlefield’s administration sees added benefits to collaborating with Siemens for a comprehensive solution for breast cancer screening, detection, and follow-up. Having patient data linked with Siemens syngo Suite radiology information system (RIS) and picture archiving and communi-cation system (PACS) solution has resulted in numerous efficiencies, for example, in scheduling patients, performing the exam-ination, interpretation, reporting, and archiving of patient data, including exam-inations performed on different modali-ties like ultrasound in the same database, according to Barbara Marshall. “Information for each modality is easily entered into the system, and it is ready to be downloaded at any workstation,” she says, adding that workflow is also improved by the fact that all of the systems are positioned near each other, off the same corridor. The new imaging devices are both more comfort-able for patients and easier to work with for staff, and the timesaving factor is significant. “The time that we are able to dedicate to patient care is greatly owed to the fast and easy workflow at the sys-tems themselves as well as when reading images and dictating results,” Nelson says.At the October 2007 American Society for Therapeutic and Radiation Oncology (ASTRO) Annual Meeting, Outpatient Care Technology named Battlefield one of the nation’s Top Imaging Centers of Excel-lence for the year. What made the center an award-winning facility in just three years was its rapid adoption of the newest and best breast imaging equipment available, its caring staff, and its solid collaboration with Siemens.Before the center opened, says Marshall, “We have a vision – taking women through the journey from discovery to recovery, touching one life at a time. We wanted the center to be a spa-like setting.” She does not talk about patient satisfaction, but rather sets a higher bar: patient loyalty. With early detection helping to reduce the need for long-time therapeutic treat-ment – allowing many women diagnosed with cancer to avoid pain and suffering and continue to lead happy, productive lives – the Battlefield team should have an attainable goal.

Continued on page 3529Medical Solutions · December 2007 · www.siemens.com/medical-magazine

Breast Cancer


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DETECTION / seek

CAD in Mammography

syngo MammoCAD* marking a suspicious lesion for further review – a mass and a cluster of microcalcifications

Computer-aided detection (CAD) software offers radiologists a second look at lesions that might other-wise be missed on full-field digital mammography. CAD algorithms are written to identify specific cancer mor-phologies. It can minimize mistakes in interpretation when radiologists tire from reviewing mammograms repetitively. The advantage of CAD is that it flags areas of concern for a radiologist to reexamine. Tommy E. Cupples, MD, a private practice radiologist at ImageCare in Columbia, SC, USA, has been a leading proponent of CAD. According to Cupples, CAD can direct the radi-ologist’s attention to possible areas of concern, but it cannot establish the diagnosis. “It still remains up to the radiologist to determine whether or not the CAD find-ing is ‘actionable,‘” he says. And in that sense, he explains, the technology is only as good as the accuracy of the mammographer. Where he has found CAD to be espe-cially valuable is in flagging small, early-stage lesions, and lesions in younger women. “These are the ones that are most likely to be overlooked and where CAD makes the most difference,” says Cupples.

Automated Breast Scanning (ABS)Operator dependency is a great issue in ultrasound, but with the addition of U-Systems, Inc., SomoVu™ Automated Breast Ultrasound System, it could soon be overcome. SomoVu breaks new ground in its ability to visualize dense breast tissue. The system produces standardized, reproducible 2D and 3D images.Workflow improvements in patient care, as well as operational and financial aspects are substantial, accord-ing to André-Robert Grivegnée, MD, who has been using the scanner for about a year. Its automation feature cuts nurse and physician time in half, notes Grivegnée, Professor and Clinical Chief of Breast Imaging at the Institut Jules Bordet in Brussels, Belgium. “With conven-tional ultrasound, it takes physicians between ten and 15 minutes to do a scan; it takes less than five minutes with SomoVu,” he says. “Now, we can do six scans per hour instead of three to four.” The improved patient workflow leaves more time for patient care as well.“Patients like SomoVu because there is less compression, just contact on the skin, and they don’t perceive the exam as aggressive,” says Grivegnée. Another advantage, he notes, is that all of the data are stored, allowing radi-ologists to review the information later.

Coronal view of a breast cyst identified with SomoVu Automated Breast Ultrasound System distributed by Siemens

* Not available for sale in the USA.

Medical experts from the USA, Germany, Belgium, France, Netherlands, and Japan talk about the latest Siemens innovations for breast cancer.

Breast Cancer

Much research and development in breast imaging is geared toward developing devices that offer increased specificity.eSie Touch™ Elasticity Imaging is a prom-ising, novel technique under study. Richard G. Barr, MD, PhD, Professor of Radiology at the Northeastern Ohio University College of Medicine and Radiologist at the South-woods X-Ray and MRI in Youngstown, OH, USA, describes how it works. “An elasto-gram differentiates relative hardness and softness of tissue,” he explains. “Initial find-ings indicate that elasticity technology has

Walk into breast imaging centers around the world and one of the first things you notice is the expanded use of breast MRI. Since the publication of a March 29, 2007 article in The New England Journal of Medicine that showed how breast MRI helped detect cancer in the contralateral breast that was missed with mammogra-phy, more facilities have become interested in this modality, especially for high-risk women. In the meantime, new American Cancer Society guidelines advise using breast MRI for high-risk women, including those with BRCA1 or BRCA2 mutations. Mitsuhiro Tozaki, MD, Director of the Breast

Biopsy-proven invasive ductal carcinoma as detected with eSie Touch Elasticity Imaging – area of stiffness in black

Left: syngo GRACE breast spectroscopy including choline quantification

Right: Lobular Cancer with lung metastasis and axillary lymph nodes Courtesy of: First Hill Diagnostic Imaging Center, Seattle, WA, USA

Center at Kameda Medical Center, Chiba, Japan, supports that indication: “MRI is a very sensitive modality. The results are compelling.”Recent studies now suggest that when breast MRI spectroscopy is added to con-ventional breast MRI, specificity increases to nearly 90 percent. Dr. Tozaki has imaged 1,500 patients with breast MRI and 700 patients with the Siemens breast spectros-copy application syngo® GRACE.With syngo GRACE, choline can be detected in breast cancers, which is considered an indicator of the activity of breast neo-plasms and the viability of breast cancers.

high specificity for the investigation of breast lesions. It uses normal respiration and movement to monitor changes in the shape of tissues with movement, and it is fairly easy to perform.” The technique is a software modification of a routine ultrasound exam, yet with no noticeable difference to the patient, while still offer-ing diagnostic confidence to both the physician and the patient.A preliminary study of Siemens eSie Touch imaging software conducted by Barr revealed an extremely high speci-ficity. Elasticity Imaging was tested in a population of 80 patients with 123 suspi-cious lesions. It correctly identified 17 of 17 malignancies. It predicted 105 of 106 benign lesions. If these findings are validated in a larger trial, Barr anticipates that Elasticity Imaging will become an

DIAGNOSTICS / find

Breast Spectroscopy, syngo GRACE

Elasticity Imaging

Therefore, Siemens breast MRI spectros-copy, syngo GRACE, shows great promise as a way to differentiate between benign and malign lesions, and to gauge the effect of chemotherapeutic agents in patients with locally advanced breast cancer.Tim® technology adds further benefits to MRI imaging in breast cancer patients: Thanks to its automated coil selection, breast spectroscopy and a whole-body exam for metastases can be done in one exam, without patient or coil reposition-ing.“Spectroscopy acquisition takes between five and seven minutes, whole-body imaging with MRI 35 minutes, and for MRI plus MRI spectroscopy, it’s 40 minutes. Acquisition with Tim is totally automatic,” Tozaki says. “I am also very positive about using MRI after chemotherapy for moni-toring.”

adjunct to other breast imaging tech-niques. Currently, a multicenter trial is underway at three facilities located in Europe (London, Paris), Australia (Brisbane), and several sites in the USA.


Breast Cancer

PET-MRI: Improving MRI Specifi city

Patient shown in 3D with arrow indicating a two-centimeter lesion confirmed as

moderately differentiated invasive ductal carcinoma. Yellow, shown transparent, is

the MRI scan; the fused PET lesion and other high-activity regions are superimposed in

green. Lesion is inside left breast, whereas the other high activity regions are in front of

and beneath the MRI scan.

LymphoscintigraphyWhen Homer Macapinlac, MD, is asked if he thinks the future of breast imaging rests on hybrid technologies, he answers emphatically: “Once you drive a Lexus, you can’t go back to a [Toyota] Camry…it’s like night and day.” Macapinlac, Professor and Chairman of Nuclear Imaging at MD Anderson Cancer Center in Houston, TX, USA, has been conducting lymphoscintigraphy research on Siemens Symbia® TruePoint™ SPECT·CT, (single photon emission computed tomography-computed tomography) used for pretreatment planning in breast sentinel lymph node excision. MD Anderson Cancer Center was one of the first facilities that acquired the hybrid system.“What’s novel about it is that you perform two exams in the same sitting – we can acquire the CT scan right after the SPECT and fuse the image,” he explains. “The result is more precise localization of the node, which CT alone does not offer. Here, we call it ‘SPECT-ACULAR-CT.’”Symbia accelerates workflow in several ways, according to Macapinlac. Elimi-nating multiple sittings is a significant time saver. Offering surgeons the ability to see the lymph nodes draining on the fused image gives them added anatomic information and helps them find the lymph nodes faster; surgery becomes easier to perform, time in surgery is shortened, and patients spend less time under anesthesia. Even though Macapinlac is impressed by early results, he emphasizes that before Symbia is widely adopted for breast lymphoscintigraphy SPECT·CT imaging, further research is imperative.

99mTc-Sulfur Colloid SPECT·CT lymphoscintigraphy performed on a patient with primary breast carcinoma accurately localizes two sentinel lymph nodes in the axilla for further biopsy.

Setting out to improve the specificity of breast MRI is a major objective of ongoing breast cancer research. Ideally, with increased specificity, women could be spared invasive procedures, such as biopsy, fine needle aspiration, or resection.Linda Moy, MD, Marilyn Noz, PhD, and colleagues at New York University School of Medicine’s Department of Radiology, have been evaluating whether images from Siemens PET·CT, when fused with MRI images from the department’s Siemens MRI systems, yield added specificity to breast MRI. For the PET exam, they used a proto-type prone positioning device. So far, fusing prone PET scans with standard breast MRI scans has demonstrated increased specificity.Dr. Noz reports that her fusion results have been quite good. “MRI gives you localization, and PET picks up the FDG [18F-fluorodesoxyglucose],” she says. “Standard supine acquisition PET is useful for staging distant metastases, but is less adequate in breast tissue

itself. Using MRI alone, the specificity was about 50 percent, but when com-bined with prone PET, the specificity rose to 95 percent.”The prototype device allows patients to be imaged by PET in the prone position as is customary with MRI scans. In a preliminary study of 45 lesions in 22 patients, sensitivity and specificity for MRI were 92 percent and 52 per-cent respectively. When MRI and PET were fused, the sensitivity declined to 83 percent, while specificity in-creased to 95 percent. An additional 14 patients have been studied since, and the pooled analysis confirms the initial results.


Breast Cancer

Superior engineering, enhanced workflow, and, above all, more precise tissue characterization are features that distinguish the SOMATOM® Definition AS* scanner from other computed tomography (CT) systems on the market. As the world’s first adaptive scanner, “It can provide a reliable diagnosis for virtually any clinical question,” says Werner Bautz, MD, Professor of Radiology and Medical Director at the University Hospital of Friedrich-Alexander University in Erlangen, Germany. In the setting of breast cancer, the innovative scanner is particularly valuable for staging lymph node involvement, as well as lung, liver, and bone metastases. Thanks to its 78-centimeter gantry bore, it is also perfectly suited for CT-guided ablation therapy procedures. Bautz notes that the new system’s features raise the bar for the industry. “Acquisition takes only a couple of seconds, and the entire diagnostic workflow is faster,” he says.SOMATOM Definition AS works with the syngo® CT Oncology (see page 70) and syngo WebSpace (see page 46) follow-up and workflow solutions. Thanks to the first, “You can tell whether the treatment is working or not right away because you can automatically track changes in tumor volume,” says Bautz. And with syngo WebSpace, “Images can be viewed with a single mouse click at any computer with Internet access,” for example, when getting a second physician’s opinion.

CT-guided ablation therapy for a metastatic lung lesion

Serum Tests: HER-2/neu

Siemens Medical Solutions Diagnostics is bringing medical oncologists an HER-2/neu serum biomarker test for monitoring metastatic breast cancer. Professor Jean-Pierre Lotz, MD, Chief Medical Oncologist at Université Pierre et Marie Curie’s Hôpital Tenon in Paris, France, said that he began studying the serum test five years ago, at the directive of the French Ministry of Health.The serum test measures circulating HER-2/neu extracellular domain (ECD); longitudinal changes in serum levels reflect the effectiveness of treatment. Lotz says that baseline serum tests are necessary to see longitudinal changes, which could

guide therapy. “My first experiences with measuring serum HER-2/neu for metastatic breast cancer showed that after patients were given chemotherapy, if the treatment was working, serum levels would rapidly decrease in the first three to four weeks after treatment,” says Lotz. “We confirmed our serum readings with a CT scan.”Christine Druther, MSPH, breast cancer survivor and founder of the HER-2 Support Group, calls it a “wonderful” test that monitors progression when other serum tests, such as CA15-3 and CA-125, fail. “People who are not getting it are being underserved,” says Druther.

The serum HER-2/neu test is an FDA-cleared blood test to help doctors monitor changes in the serum HER-2/neu levels and to manage the therapy of women with metastatic breast cancer.

Staging with SOMATOM Defi nition AS

THERAPY / act

34 Medical Solutions · December 2007 · www.siemens.com/medical-magazine

* Status at editorial deadline: The information about this product is being provided for planning purposes. The product is pending 510(k) review and is not yet commercially available in the USA.

Breast Cancer

Looking Forward, Looking BackWhen radiologists in the future look back on the evolution of breast imaging within the last 40 years, they will see that mam-mography opened an entirely new field. Analog mammography was the first imag-ing tool demonstrated to save lives, and it remained the cornerstone of breast screening for years to come. The outlook for breast cancer patients would be for-ever changed – early detection proved an achievable goal. Eventually, though, the limitations of analog mammography caught up with it: There was a high false-negative rate and difficulty imaging young women and those with dense breast tissue. Mammography’s functionality was also limited. Women disliked its harsh com-pression, and workflow was laborious.Responding to the need to overcome these drawbacks and move breast imaging towards the next generation, they will see that Siemens and its research collabo-rators and customers have stepped up to the plate to develop new solutions in this critical area of healthcare. As a result, today’s screening systems are less intimi-dating for the patient, yet they offer far

better tissue characterization and more specific staging, in addition to providing improved patient surveillance.Who would have envisioned that digital mammography, MRI, and ultrasound would eventually be recommended as standards of breast cancer screening and care, even at a community imaging center? Dr. Nelson says that offering the most advanced imaging technology has been a key to making the ’journey’ for his patients a little easier, and has resulted in building a larger patient base, assuring patient loyalty, and streamlining workflow to free time for patient care. It has also had a positive effect on the bottom line: Early adoption of these devices has paid for itself quickly, according to Nelson.Today, Siemens is working with several collaborators around the world to develop all-in-one breast care solutions that en-hance patient, operational, and financial results. Comprehensive imaging solutions also have unprecedented flexibility and functionality. Siemens has also diversified its breast care capabilities far beyond adding greater specificity to breast cancer

Adaptive Radiation Therapy

Adaptive Radiation Therapy (ART) is designed to provide feedback to the radi-ation oncologist immediately before or during treatment so therapy can be adapted to anatomical changes and shifts in patient positioning. A primary goal of ART is to ensure that the therapeutic dose is delivered precisely to the target and that surrounding healthy tissue is spared as planned. This is especially important with breast irradiation, because the breasts are close to the heart and lungs.Professor Philippe Lambin, MD, Head of the Department of Radiation Oncology at MAASTRO Clinic in Maastricht, Nether-lands, is impressed with the ARTISTE™* Solution from Siemens, the next genera-tion in ART. “You are able to set up the beam so that the heart and lungs are not

in the radiation field,” he says. Innovative In-Line™ imaging technology allows clinicians to tailor radiation therapy to the patient’s changing anatomy.“With entrance-and-exit dosimetry, you know precisely where in each part of the body the dose is,” explains Lambin. “An advantage of ARTISTE is that the system images in the axis of the beam, not per-pendicular to the beam. The image quality is much better. This has really changed physician quality control.”Additional features that Lambin finds appealing are its flexibility in working with Image-Guided Radiation Therapy (IGRT). “Given ARTISTE’s built-in flexibility,” he says, “we do not need to immobilize the patient with a special frame for stereotactic radio-therapy.” Lambin adds that molecular and

Providing accurate dose distribution, the 160 MLC™ Multileaf Collimator is a standard feature on the ARTISTE Solution.

functional imaging will be the next hurdle to overcome. “Radiation therapy has been given in a homogeneous fashion, and we know tumors are not homoge-nous.” Today, together with Siemens, his clinic is at the forefront of this research, and is forging a new path in ART.

Continuation from page 29

Laura Newman is an award-winning medical writer based in New York, NY, USA. She is the author of numerous feature articles about emerg-ing medical technologies. She was also the editor of Medical Outcomes & Guidelines Alert, a newsletter widely read by the pharmaceutical and medical device industry.

Further Informationwww.siemens.com/breastcarewww.changethestatistic.com

screening. Hybrid devices, such as Symbia® TruePoint™ SPECT·CT, build on the strengths of their individual compo-nents, evaluating distant metastases and using imaging for more targeted and safer treatment planning. Beckoning on the horizon are individualized treatments, such as the Siemens ARTISTE™ Adaptive Radiation Therapy solution, as well as molecular and functional imaging. All of these developments point to a future that looks brighter than ever in the fight against breast cancer.


* Not available for sale in the USA.

The introduction of the electronic health record at 46 hospitals of RHÖN-KLINIKUM AG is the largest privately-fi nanced IT project in the German healthcare industry – and may send an international signal.

By Notker Blechner

Trendsetter in eHealth

Dietmar Pawlik, an acting Member of the Board at RHÖN-KLINIKUM AG, and Volker Wetekam, President of Global Solutions Division at Siemens Medical Solutions, are the two managers responsible for intro-ducing the electronic health record (EHR) at the hospitals of RHÖN-KLINIKUM AG. In an interview with Medical Solutions, they explain the benefits and challenges of the joint project. RHÖN-KLINIKUM AG has been working with electronic health records for some time now, and is one of the pioneers in the implementation of digital technology in the clinical sector in Germany.

Digitization has taken hold in most industries. In the healthcare industry, however, diagnostic reports are still written by hand and X-ray images are sent by regular mail. Why hasn’t the digital age reached the healthcare industry by now?

Dietmar Pawlik (right), Board Member of RHÖN-KLINIKUM AG, hopes for improved processing thanks to the electronic health record. Wants to integrate all medical technology and information technology in healthcare: Volker Wetekam, Head of Global Solutions Division at Siemens Medical Solutions.

Electronic Health Record


PAWLIK: Digitization in hospitals is far more advanced than one may think. Many treatment processes are supported digi-tally – to a much greater extent, however, in diagnostics than in process organiza-tion. Through the use of modern imaging methods such as computed tomography [CT] and magnetic resonance imaging [MRI], the percentage of the digitally supported value-added chain has now reached 50 to 60 percent.

WETEKAM: The data generated digitally – whether at a CT system or in a lab – are, however, not integrated in a centralized environment; they are stored separately at a variety of locations and systems. Most hospitals and physicians in private practice would rather store their data in their own facilities instead of using a modern computer center, where data would be available across hospitals and around the clock.

The e-card is coming into increased use worldwide. It will soon be introduced in Germany. Will this further accelerate the digital revolution in the healthcare industry?WETEKAM: I do not think the introduction of the electronic health card will result in significant structural changes. It merely represents a change in medium from paper to card. The electronic health card makes sense only in conjunction with value-added applications. The process will not change until the electronic health record is introduced.

To what extent?WETEKAM: With the electronic health record, care-relevant data from diagnostic findings, diagnoses, radiography, CT as well as MRI images, electrocardiograms [ECGs], lab values, therapy measures, and treat-ment reports, can be stored digitally and exchanged between hospitals. This will, for example, reduce unnecessary examina-tions and the prescription of incompatible medications. In addition, processes and hospital stays will be shorter. Patient care will be optimized and physicians will be relieved of unnecessary work. These sav-ings are far greater than the costs associ-ated with introducing the health record.With stroke patients, for example, the electronic health record can be a lifesaver. While the patient is examined in the ambulance on the way to the hospital, the data are already available there. Even before the patient arrives, the physician can decide whether or not to perform a head CT. Thanks to the electronic health

record, therapies can be initiated much earlier, saving valuable brain cells.

What is RHÖN-KLINIKUM AG doing to promote the electronic health record?PAWLIK: We started thinking about digi-tizing patient records several years ago. The question for us was how we could take the knowledge and documentation spread throughout our clinics and make them available to other institutions in the RHÖN group. In 2002 and 2003, we developed the concept of the teleportal clinic, which is very much based on the use of teleradiology. At the same time, we had the objective of introducing an electronic health record throughout Germany. In 2005, the project was set up in a lab situ-ation. Since then, the system has been arranged and the technology works. We have established prerequisites regarding data protection regulations within the organization, as well as access mecha-nisms: If a cardiologist in the medical care center wants to see a digitally stored ECG performed in the clinic, he can retrieve it, given he is authorized to do so and can verify his authorization to the system.

What is Siemens doing to promote the electronic health record?WETEKAM: First, we aim to integrate all medical technology and information technology in healthcare. We offer the electronic health record as a practical solution. For years, we have invested a lot of research and effort in the develop-ment and enhancement of the electronic health record, and are working together


“Our goal is to integrate other hospitals using different systems to pro-vide services.”

Dietmar Pawlik, CFO,

RHÖN-KLINIKUM AG, Germany

“The electronic health card repre-

sents a change in medium – not

in structure.”

Volker Wetekam, President of Global Solutions Division,

Siemens Medical Solutions, Erlangen, Germany


PAWLIK: RHÖN-KLINIKUM AG has been working very closely with Siemens in all fields of medical technology since the 1980s. Since then, we have developed a number of projects, and have provided requirements that Siemens has imple-mented. At the moment, we are building the Center for Particle Therapy for €120 million in Marburg, Germany, with Siemens as the technology supplier. Our coopera-tion over many years has developed into a cooperative relationship with Siemens. Of course, it would have been possible to entrust a project like WebEPA to a younger software company. But we expect Siemens to represent far more potential for us. For this reason, the cooperative agreement has been set up for a longer period of time.

What type of other potentials do you mean?PAWLIK: We have the opportunity to generate knowledge with the electronic health record. At present, we are investi-gating the development of a knowledge database for stroke patients.

WETEKAM: In the final project phase, we want to use the record as a knowledge-based medium. It certainly helps that RHÖN-KLINIKUM AG has scientific partners such as the German University Hospitals of Marburg and Gießen working with it.

Was there any skepticism or resistance to the project from patients or physicians?WETEKAM: There was no general skepti-cism among patients. Naturally, there were a few loud voices who warned against ‘the transparent patient.’ We were able to eliminate these fears to a great extent through the two-year pilot project we just completed in April 2007. We had many discussions with physicians who feared

technology because their dealings with patients would be much more visible than before. Now, however, most physicians recognize the benefits. Practical experien-ces during the pilot project have even resulted in a fascination for the technology among some of them. They enjoy partici-pating in the project because they have seen that the record improves their per-formance.

What is the economic importance of the EHR project?WETEKAM: Through digital integration of the hospitals of RHÖN-KLINIKUM AG, we will be in a position to offer high quality at a price that also covers costs in the future.This project could serve as the initial spark within the German healthcare industry. In Germany, we are spending €1 to 1.4 billion to distribute 80 million electronic health cards. An enormous data highway is being built, but no one considers how to use this infrastructure until the tar is dry. Through the EHR project, we want to show feasible, value-added applications for the health card.The project also increases RHÖN-KLINIKUM AG‘s competitiveness. Once all 46 clinics are connected, the company can offer the solution to other hospitals. All of the little networks currently being established in Germany are predestined to work with RHÖN-KLINIKUM AG. Discussions are cur-rently underway with Lich Hospital, near Frankfurt am Main, Germany, which is not part of the RHÖN group. We have a good chance of becoming the standard plat-form for the electronic health record in Germany.

Aren’t you being a bit optimistic? The German healthcare system does not have a uniform standard for electronic health records…

with excellent partners in healthcare. We are far ahead technologically, and our development is two years ahead of our competitors. This can also be seen in the fact that we are winning an increasing number of large projects in Europe – most recently in Scotland and France.

You have been cooperating with RHÖN-KLINIKUM AG on the electronic health record for two years. Now, the group will implement the Siemens eHealth solution Soarian® Integrated Care in 46 clinics. What do you see as the promise within this partnership?WETEKAM: The partnership with RHÖN-KLINIKUM AG is very important to us. It is our closest and most strategic cooperation worldwide. We see RHÖN hospitals as the ideal partner, not only because they prac-tice excellent medicine, but also because they are efficiency-oriented.


“The objective is to offer interoperability across sectors and providers.”

Dietmar Pawlik, CFO, RHÖN-KLINIKUM AG, Germany


WETEKAM: Having all 2,200 hospitals in Germany use our Soarian Integrated Care is not our objective. We also support the electronic case record [ECR] initiative, which is examining how the electronic health records of different providers could work together. Supporting standard inter-faces like HL7, we will continue develop-

Notker Blechner has been working since 1984 as a journalist in economics and reports on global trends – from corporate sustainability to private equity. His articles have appeared in Die Welt, Frankfurter Rundschau, Financial Times Deutschland, VDI-Nachrichten, and the French press. At present, the well-traveled German works primarily for the broadcast station Hessischer Rundfunk (hr).

ing Soarian Integrated Care to make it easier to connect with other systems.

PAWLIK: We have established it as an open system from the very beginning. We do not want to use the electronic health record to exclude service providers. Our goal is to integrate other hospitals using different systems to provide services. Thereby, we can accomplish interopera-bility across sectors and providers. When the clinics of RHÖN-KLINIKUM AG show the benefits, other hospitals will follow our example.

What can be learned internationally from a German project?WETEKAM: The idea behind the ECR pro-ject in Germany can be applied globally. If the project is successful, we could be a trendsetter worldwide.

Do you sometimes feel like a do-gooder?PAWLIK: Breaking new ground is always wrapped up somehow with idealism. I believe our high expenditures will pay

Further Information

www.siemens.com/ehealthsolutions


off in the future and the project will be profitable.

WETEKAM: Yes, I feel like a do-gooder, somewhat. A huge project such as this requires a lot of idealism. I am certain that this project will change the impor-tance of IT in the healthcare industry more than ever before.

Thousands of people die annually in emergency situations because there is no information available on previous illnesses or prescribed medications. The electronic health record aims to change this. It shares diagnostic findings, radiography images, ECGs, treatment reports, and other data, all in a digital format. As a result, health-care data are available quickly and can be accessed by authorized physicians as needed. Incorrect treatment of emergency cases, incompatible medications, and duplicate examinations can be reduced. The result is improved, more cost-effective care for patients. Physicians and nursing staff should be relieved of unnecessary tasks, giving them more time to care for patients.

The Electronic Health Record (EHR)

Since there are still no uniform standards for electronic health records, most hospitals work with a variety of software systems. To exchange case-related patient data or radiography images across software platforms, a number of private hospital networks and public hospitals have established a consortium. Within the electronic case record network, RHÖN-KLINIKUM AG is cooperating

The Electronic Case Record (ECR)

with German Asklepios Kliniken, Sana Kliniken GmbH & Co. KGaA, public institutions, and the Fraunhofer Institute for Soft-ware and System Technology. They are currently testing the use of case records in a pilot project. The objective is to establish system interoperability while taking into account data protection regulations and technical security requirements.

According to the German Federal Health Ministry, 10 to 20 per-cent of the €140 billion spent annually on healthcare in Germany could be saved through digitization.Numerous hospital networks are currently working on electronic health records. The largest of these projects is being performed by RHÖN-KLINIKUM AG together with Siemens. The WebEPA will be implemented in all 46 clinics of the RHÖN-KLINIKUM group. During implementation of the Soarian Integrated Care software solution, 130 information systems have to be linked. Over 15,000 users will work with WebEPA, and more than 1.4 million patients are treated every year.



Today, improved magnetic resonance imaging with Tim technology provides for much more accurate prognoses regarding the therapeutic success for osteoarthritis in the hip. This should greatly support and increase the utilization capacity of the Radiology Department of the private Sonnenhof Hospital in Berne, Switzerland. The drivers of this boom could be new fi ndings in the pathogenesis of hip impingement arthritis. These are presently determined through cooperative efforts between Sonnenhof Hospital and Inselspital Berne.

By Oliver Klaffke

The reception reminds one of an elegant designer hotel rather than the admission area of a radiology department. Things are not much different in the medical area immediately behind the sliding frosted glass doors. The equipment is modern and exudes the impression that professionalism and service are taken seriously here. The magnetic resonance imaging (MRI) systems of the private Sonnenhof Hospital Berne work nonstop. Densely packed examina-tion plans glow on the screens in the hall-way, showing that the diagnostic work in the hospital is precise, quick, and stan-dardized. “We have modernized the depart-ment during the last two years. And right now, an additional MRI examination room

is under construction,” explains Stefan Werlen, MD, Head of the Radiology Department. For the private hospital’s key stakeholders, investments into the infra-structure of a completely new radiology department will bear success, not only from a medical point of view, but also from a financial one.The simplified workflow saves valuable time – time that can now be invested into the diagnosis of images, which in turn results in better quality. ”We believe that the future importance of MRI examinations will increase greatly through the use of Tim® technology,” says Werlen. As a plat-form technology, Tim (Total imaging matrix) provides ideal prerequisites: flexi-

Research in a Niche Market

The reception area of the Radiology Department at Sonnenhof Hospital Berne reminds visitors more of a trendy hotel than a medical department.

Increasingly younger patients suffer from arthritis of the hip. Early diagnosed cartilage damage can often be treated successfully – even without an artificial hip replacement.

Market Niches in MRI


Prior to the MRI exam, contrast media is injected into the affected hip (above). Tim technology then enables fast coil placement (top right) and acquisition. Thanks to advanced software, image analysis is also sped up. The contrast media accumulates in the affected cartilage tissue, making it clearly visible on the images.

bility through versatile coil combinations, accuracy through high signal strength, as well as spatial resolution and speed resulting from parallel imaging.These improvements enable completely new diagnostic possibilities in the future, among them in orthopedics. The new MRI techniques also allow for scientific exami-nations rarely performed to date. For that

purpose, the systems did not deliver the necessary resolution, user-friendliness or speed. But that has now changed.

Better Images through Tim

In the next ten years, the percentage of the population that is older than 55 years will increase considerably in Europe and

North America. Given this fact, the demand for first-class diagnostics in orthopedics will increase as well. This demand will be amplified by advances in diagnostics made possible through the improved image quality and easy handling delivered by Tim. Together with Tallal Charles Mamisch, MD, of the Department of Orthopedic Surgery Inselspital Berne, Dr. Stefan Werlen is par-



ticipating in research projects that show the considerable potential of the new MRI system generation. Their initial results indicate that the predictability of a success-ful therapy is greatly improved. As a result, a completely new range of applications is available for MRI examinations that could be of great interest, both medically as well as financially. “Radiology departments that

use state-of-the-art diagnostic technolo-gies will certainly benefit from these developments,“ says Werlen. He hopes for his department that the high quality stan-dard for diagnoses prevails and that his customers – and this includes referring physicians as well as patients – will not be satisfied with anything less than the reso-lution and speed of examination provided

by Tim. “This applies to the use of MRI in orthopedics, for example, when examin-ing hip arthrosis,“ says Stefan Werlen. In many cases, only hip surgery shows that the articular cartilage has just about dis-appeared – despite being visible on X-ray images prior to surgical intervention. The reason for this is the pathological change in the biochemical composition of the



cartilage. It seems intact on the X-ray image, although the contents of proteo-glycans have already decreased and there-fore the cartilage structure is damaged. But syngo® MapIt, a sequence and post-processing package for quantitative MRI assessment, provides approaches to as-sess proteoglycan decrease before surgery. With the help of this software, the deficit of proteoglycans is visible onscreen. The radiologist is able to provide the orthope-dist with essential decision-making tools. He or she is able to state, with a high degree of reliability, whether an artificial hip joint is required because too much of

the cartilage has been destroyed. If enough cartilage is available, joint pre-serving treatment can be initiated.

Attractive Market Niche

Because the radiology team at Sonnen-hof Hospital is highly proficient in these diagnostic techniques, it was able to develop a highly attractive market niche. Orthopedists from the surrounding area who want to err on the side of caution and want the best possible information about the status of their patients’ hips refer them to Sonnenhof Hospital for examination. “The rise in demand justifies the investments in the infrastructure of our department,“ says Werlen. In addition to the quality of both images and diagno-ses, the service has to be suitable as well for the referring orthopedists: They receive reports and images on the same day. To ensure this, an easy system operation and an efficient workflow are necessary. “We can meet our own demands and the expectations of our customers only when the handling of both system and evalua-tion software is as easy as possible.“ This saves time and money and provides enough breathing room for a sometimes time-consuming diagnosis, which is im-portant in the interest of optimal service.

Preventive Approach

“Tim, combined with syngo MapIt, will greatly improve the early detection of, for example, impingement-induced arthritis,“ explains Mamisch. Impingement-induced arthritis is the result of a misshapen femoral head impacting the acetabular socket. Werlen and Mamisch assume that damage to the hips relates for the most part to impingement. The scan of the articular head frequently shows small bone protuberances which are responsible for the damaging impacts. The source for these changes in the bone is completely unknown. Over time, however, the mechanical effect destroys the articular cartilage. The earlier the impacts are detected, the more promising the success of therapy. For this purpose, Mamisch and Werlen are conducting screening studies to detect the prevalence of changes in the hip joint during adolescence. The preven-tive approach is of major importance: The study should detect the risk for serious, long-term hip damage early enough to

Challenge:• Increase business to be able

to afford latest MRI technology and use it at full capacity

Solution:• Transfer of new techniques in

high-end research in disease fields with increasing incidence

• Develop a research platform to document the leadership role in those fields

• Exploit improved workflows and throughput

• Offer high-quality diagnosis and fast reporting

Result:• Expanded scope of applications• Increased referrals• Systems operate at full capacity

Summary

“The rise in demand justifi es the investments in the infra-structure of our department.”

Stefan Werlen, MD, Head of the Radiology Department, Sonnenhof Hospital, Berne, Switzerland



Oliver Klaffke is a scientific and economic journalist. He writes for Nature, New Scientist, and Bilanz, a Swiss business magazine.

determine who will most likely require an artificial hip joint sometime in the future. If it is possible to determine the adoles-cents who run the risk, it may be possible to remove the bone appendage with a simple surgical intervention. This type of development would be of enormous eco-nomic importance. The costs incurred through nonproductive times due to hip damage are enormous: “Calculations show that they are as high as approximately one percent of the gross domestic product,” adds Mamisch.Werlen and Mamisch also extend the research for the sources of impingement-induced arthritis to athletes. It is known that certain types of sport activities fre-quently cause damage to the hip joint or are prevalent in high-performance athletes. A lot of ice hockey players and fencers suffer from severe damage to the hip joint.As likely as not these are impingement-induced arthritis. “The causes for their accumulated occurrence in athletes are vague at the moment,” says Werlen. The scientists assume that during the adoles-cence of athletes, certain movements interfere with bone growth in the joints, which in turn are responsible for impinge-ment-induced arthritis.

The Road of a Private Hospital

Stefan Werlen suggests another diagnos-tic field for Tim technology: prostate examinations. To date, these are difficult to perform with conventional MRI systems

and do not meet the quality required by a diagnostician. The potential of Tim in prostate diagnostics has not been tapped. Considering the aging population, the frequency of prostate tumors is rising, and the number of associated preventive medical check-ups is increasing as well. Tim offers a host of promising possibilities. Up until now, MRI examinations were not considered an alternative to biopsies. However, biopsies are time-consuming and uncomfortable for the patient. Tim tech-nology could make for easy and highly reliable routine examinations with MRI, according to Werlen and Mamisch.Today, physicians rely heavily on prostate specific antigen (PSA) value when diagnos-ing prostate cancer. If the value is elevated, it is seen as a tumor indicator. With the improved MRI method, it seems possible to detect the tumor directly onscreen. “This enormously increases security for the patient,“ says Werlen. The risk of false-positive diagnoses is reduced, because the treating physician is able to assure himself of the presence of the tumor. In addition, close viewing of the tumor also enables a more secure, exact localization of the tumor in case of surgical intervention.”From a hospital’s economic point of view, this opens up interesting possibili-ties,“ believes Werlen. “The example from orthopedics and the potential of prostate examinations clearly demonstrate that modern MRI equipment with Tim technol-ogy is an economically feasible investment especially for a private hospital which has

to financially stand on its own two legs.“ The race for referrals in radiology will be won by those who are able to provide the highest quality standards in diagnostics and service.

Further Informationwww.siemens.com/MAGNETOM-1-2007www.siemens.com/news-prostate-biopsy

“Tim, combined with syngo MapIt, will greatly improve the early detection of, for example, impingement-induced arthritis.”

Tallal Charles Mamisch, MD, Department of Orthopedic Surgery,Inselspital, University Berne, Switzerland

Remote Solutions

Associate Professor Anders Persson, MD, Director of the Center of Medical Image Science Visualization (CMIV), Linköping University Hospital, Sweden, appreciates the improved workflow with syngo WebSpace.


Remote Solutions


“Let’s take a closer look at the vessels,” says Bernd Wintersperger, MD, Associate Professor of Radiology and cardiac imag-ing expert at the Department of Clinical Radiology of the University of Munich Hospital (Großhadern Campus), Germany. At the 12th International Magnetic Reso-nance Imaging (MRI) Symposium in Gar-misch-Partenkirchen in Germany, Bernd Wintersperger takes over the mouse con-trol and does this demonstration scan via online access from a regular computer at the speaker’s podium. His audience intently observes the screen.

Patient in Munich, Scan Control at Symposium

The 41-year-old patient is beeing scanned in the MAGNETOM® Trio MRI system in Munich. Cardiac expert Wintersperger starts scanning right from the Garmisch-Partenkirchen conference room. syngo® Expert-i is for use only within the hospital enterprise, but for this demonstration, a secure broadband virtual private network (VPN) connection to the hospital network

was made possible at the symposium. The images show that the diabetic (type 1) patient demonstrates significant vascular changes, but no evidence of myocardial infarction. This presentation was made possible by syngo Expert-i, the unique application available for Siemens MRI and CT (computed tomography) systems. Wintersperger calls the application “very impressive,” and the audience follows the live scan enthusiastically.Apart from complex demonstration scans like the one at this symposium, the appli-cation has proven itself in clinical use. “For example, when younger colleagues have a question for experienced colleagues regarding a special examination, the expe-rienced team members do not have to go to the MRI system,” explains Bernd Wintersperger. The experts can connect to the MR with a one-time password with-in the hospital network. Then they can consult and perform the scan. Access is possible from a computer or laptop*, the

Two modern remote solutions can display 3D/4D information not only at a workstation but also at other accesspoints within a hospital network. One tool even allows access beyond the hospital. Experts from Germany and Sweden report how these solutions have improved the quality of diagnoses and treatments as well as optimized their workfl ows.

By Katja Stöcker, MA

Direct Line to System or Data

“Using syngo WebSpace, we can call up thin-slice CT images from a standard computer or laptop. This provides us with a completely different way of working.”

Anders Persson, MD, Associate Professor and Director, Center of Medical Image Science Visualization (CMIV), Linköping University Hospital, Sweden* Computer/laptop must meet minimum requirements.

Bernd Wintersperger, MD, Associate Professor of Radiology and cardiac imaging expert at the Department of Clinical Radiology of the University of Munich Hospital (Großhadern Campus), Germany, explains the possibilities of syngo Expert-i at the 12th MRI Symposium in Garmisch-Partenkirchen, Germany.


Remote Solutions


console of a picture archiving and com-munication system (PACS), or from any other MRI system within the hospital net-work.

Certain Diagnosis and Improved Workfl ow

According to Wintersperger, the applica-tion has proven itself in larger radiology departments where individual imaging systems are not located in the immediate vicinity. “syngo Expert-i not only enables a more confident diagnosis through a second opinion, it also helps to improve workflow,” says Wintersperger, naming two decisive advantages.The cardiac expert can also imagine that remote solutions such as syngo Expert-i could optimize cooperation among the various locations of a hospital. “In case patients are being scanned at the city campus of the hospital while dedicated radiology specialists are located at the Großhadern campus, the city campus col-leagues can obtain a second opinion for particular cases,“ explains Wintersperger. Of course, this would also work the other way around. As a result, the patient does not have to be transferred to Großhadern. “syngo Expert-i can help to save time when performing special examinations, increase patient throughput, and allow for secure diagnoses,” summarizes Wintersperger. In short, syngo Expert-i helps to optimize radiology workflow.

CT Thin-slice Dataon the Offi ce Computer

Some 1,400 kilometers away from Wintersperger, Associate Professor Anders Persson, MD, also gets excited when he hears the phrase remote access. In con-trast to his colleague in Munich, the Direc-tor of the Center of Medical Image Science Visualization (CMIV) at Linköping Univer-sity Hospital in Sweden is thinking more along the lines of transferring 3D/4D image data directly from a CT scanner to a com-puter, laptop*, or PACS.Persson’s hospital colleagues, for example, in vascular surgery, have access to the same detailed data as at a workstation, but can remain in their offices or conference rooms.Previously, Persson discussed radiological findings with the vascular surgeons at

* Computer/laptop must meet minimum requirements.

Remote Solutions


morning case meetings using 2D images from PACS. “In order to plan operations better, surgeons want to see what we see, and not simply imagine it,” explains Persson. This is now possible – any time, and from anywhere. “Using syngo Web-Space, we can call up 3D CT images from a computer or laptop*.** This provides us with a completely different way of working,” says Persson enthusiastically.The easy, password-protected Internet connection to the syngo WebSpace server enables up to 20 users to work simulta-neously with 3D/4D postprocessing tools, without having to sit at a workstation. The images are sent directly from the CT system to the syngo WebSpace server. “This happens much faster than from a CT system to PACS,” reports Persson. Speed plays an increasingly important role in modern medical care, according to the Swedish Associate Professor.

Intensive Cooperation:Research and Application

The CMIV, founded in 2003 as an inter-disciplinary research center, has to do business like a private facility, despite its association with the University Hospital, and has to send monthly reports to the hospital management. “An improved work-flow and intensive cooperation with clini-cal colleagues are extremely important to our efficient research and development projects,” says Persson, describing two fundamental challenges to the CMIV.The research activities of the 70 research-ers and 31 doctoral candidates focus on the big picture. Persson and his team are researching imaging and reconstruction, image analysis, visualization, and process-ing, as well as transferring of comprehen-sive image data; such as that generated with the high-end SOMATOM® Definition Dual Source CT system. The CMIV master plan is displayed the wall: a Nobel Prize within the next 25 years. Their view extends beyond the doors of the CMIV to the adjacent floors of the University Hos-pital: The requirements and feedback from clinicians flow directly into CMIV research. In return, the CMIV radiologists, using syngo WebSpace client-server technology, forward thin-slice 3D/4D CT images from

Challenge:• Uncertainty during an exam• Live scans at conferences and

training courses• Handling detailed data beyond

the radiology department• Improved planning for inter-

ventions

Solution:syngo Expert-i• Online access to MR/CT

scanners from a computer or laptop*, for example in a conference room in the hospital

syngo WebSpace• Availability of 2D/3D/4D data

beyond the CT and MR work-station

• Access via computer or laptop, even outside the facility

Result:syngo Expert-i• Get a second opinion in

seconds, for example, for special exams

• Shorter scan times and fewer repeated transfers

• Improved workflow across multiple locations within the hospital network

• Reduced training effortssyngo WebSpace• Short-term storage of com-

prehensive thin-slice CT images• Precise planning of surgical

procedures and interventions • Improved diagnoses and advice

to patients

Summary

the CT system directly to vascular surgeons such as Claes Forssell, MD. He says: “We need, for example, very precise details regarding the position, length, and extent of aneurysms, aneurysm necks, and access vessels. The ability to look at 3D/4D images, even in my office or during surgery, sim-plifies my work and improves treatment for my patients.”syngo WebSpace is also the optimal solution for short-term storage of thin-slice CT data (less than five millimeters). Depending on the configuration, from 1.6 to almost 10 million thin-slice acqui-sitions can be stored on the syngo Web-Space server. The need for 3D/4D image data from volume CT images has grown enormously, but purchasing new or up-grading existing workstations is expensive. CMIV employees currently work at four workstations. “Naturally, they are always fully booked,” says Persson. “syngo WebSpace makes detailed CT information available everywhere, although password protected, and significantly improves workflow.” This saves money and improves the quality of treatment.

Better Advice for Patients Thanks to 3D/4D Acquisitions

Thoracic radiologist and senior physician Gunnar Wiklund, MD, notes an additional benefit: “If a patient sees how advanced the calcification is in his or her coronary vessels, he will take our advice to quit smoking and get exercise more seriously than if we were to tell him or her and show him or her 2D images from PACS.” For Associate Professor Persson of CMIV, syngo WebSpace also plays a critical role in training: “Here in the CMIV training room, I show my students the 3D/4D images from the computer directly on the screen.” Persson also trains colleagues from throughout Sweden about working with 3D/4D postprocessing tools such as syngo InSpace4D, and shows them how to design more efficient workflows with syngo WebSpace. The next course will take place in early 2008.

Virtual Autopsies Clarify Criminal Cases

One focus of the CMIV is cardiac exami-nations. The Dual Source SOMATOM Definition CT system provides Persson and

Further Informationwww.siemens.com/syngo-Expert-iwww.siemens.com/syngo-WebSpace

* Computer/laptop must meet minimum requirements.** Internet connection needed.

Remote Solutions


his colleagues with high-resolution, real-time images of the beating heart, using a low dose of contrast agent and no beta blockers. Because of its modern equip-ment, the CMIV also works on solving criminal cases. According to Persson, since the center’s founding in 2003, it has per-formed almost 200 virtual autopsies. “In some of the cases, with our modern imaging capabilities, we came up with a different cause of death than the obvious one,” reports Persson proudly. High-reso-lution, 3D imaging provides fast, precise information on injuries and fractures. Using syngo WebSpace, the information is sent just as quickly to the correspond-ing police stations and district attorneys’ offices.

Remote: Benefi cial Tools for Interaction

Persson and Wintersperger see remote solutions such as syngo Expert-i or syngo WebSpace as beneficial tools for improved interaction among experts. Both offer a more secure diagnosis in order to improve

treatments. Above all, cooperation and workflow both within radiology as well as with other hospital departments can be optimized.

Katja Stöcker works in the editorial office of Medical Solutions. Prior to this, she was a free-lance writer for Deutsche Presse-Agentur (dpa) (German Press Agency), various daily newspapers, and the online editorial office of the broadcast station Mitteldeutscher Rundfunk (mdr).

“syngo Expert-i can help to save time when performing special examina-tions, increase patient through-put, and allow for secure diagnoses.”

Bernd Wintersperger, MD, Associate Professor of Radiology, Department of Clinical Radiology,University of Munich Hospital (Großhadern Campus), Germany

Order Plan & Prepare Scan & Reconstruct Process Read & Report Distribute

Patient Preparation Scan Data (Remote access via syngo Expert-i within the hospital network)

AcquisitionWorkplace

CT/MRWorkplace

syngoWebSpace

Server

Shared Database

Fast Data Link PACSArchive

PACS Reading Workstations

OfficeLaptop

Office PC

MultiModality Workplaces +CT Clinical Engines +

syngo Expert-i

syngo Expert-i (Remote)

syngo WebSpace (Clients)

Siemens improves the workfl ow in radiology and beyond with the two remote solutions syngo WebSpace and syngo Expert-i.


The hospital system reform in Portugal has opened up a new market for private clinics. In Lisbon, private hospital operator Espírito Santo Saúde has opened one of the most modern private hospitals in Europe and relies on the holistic approach of Siemens in this project.

By Manuel Meyer

A Sense of Elation in Portugal


“We have realized a dream,” says Ivo Antão. The Chief Information, Organization and Processes Officer (CIO) of the Espírito Santo Saúde (ESS) Group proudly guides visitors through the brand-new Hospital da Luz in Lisbon, which is among the most modern private hospitals not only in Portugal, but the rest of Europe as well.The private hospital operator, part of the Espírito Santo investment group, main-tains 14 smaller healthcare centers, private hospitals, and rehabilitation facilities in Portugal.

The new showpiece hospital, with its 150 acute-care beds, has all the clinical competences of a general hospital, includ-ing more than 40 clinical specialties. In addition, as part of an Integrated Health-care Complex, Hospital da Luz also com-prises a Nursing Home unit with 130 beds and a Residential Home for seniors with 115 private apartments, providing the complete spectrum of care in a single location, which makes this arrangement unique in Portugal. “It is the first hospital we have built and managed ourselves

from the very beginning,” explains Antão. This prestige project of the ESS Group is an important strategic move in a market slowly opening to private initiatives. Some 400 physicians, 250 nurses, and 200 tech-nicians and support personnel work at Hospital da Luz.

Restructure of Hospital System

As in other countries, the Portuguese Government is looking to optimize hospital investments. The government has to save

The Portugese healthcare system is on the move towards private hospital investments.

Digitized Hospital


Digitized Hospital


“When looking at the integration of various information technologies, Siemens appeared to be the only company with the corresponding capacity.”

Ivo Antão, CIO, Espírito Santo Saúde, Lisbon, Portugal

where it can. As part of the reforms, the hospital system was subjected to a far-reaching restructuring phase.With healthcare costs rising by more than ten percent annually and a quickly aging population (by 2025, more than 20 per-cent of the Portuguese population will be over 65), reform was inescapable. The objective is to drastically reduce the rise in healthcare costs while simultaneously increasing quality and efficiency.Many patients in Portugal find the current wait times for examinations and surgery to be particularly annoying; for some, those wait times may even become dan-gerous. Over the past four years, the num-ber of privately insured persons has risen steadily. Physicians and hospital person-nel complain of antiquated facilities and equipment. As part of the reforms, the government is relying on private manage-ment structures and initiatives to build new hospitals and modernize existing facilities.

Good Business Opportunities for Private Hospital Operators

Despite its relatively small population of 11 million, Portugal is an extremely inter-esting market for private hospital opera-tors. There are 84 general public hospitals compared to 60 private clinics. Most of these are small private hospitals with few specialty departments. As a result, the Portuguese healthcare system remains firmly in government hands when com-pared to other European Union (EU) countries. However, the government is increasingly opening the market to pri-vate initiatives. Through its subsidiary Espírito Santo Saúde, the Espírito Santo Group has become firmly established in

the healthcare provision sector. In addition to having one of the largest private and investment banks and insurance compa-nies in the country, the group has a signifi-cative presence in sectors such as travel and tourism, real estate, and construction. Although the parent company has been active in the healthcare sector for decades through its health insurance provider Companhia de Seguros Tranquilidade and in the managed care business through Advance Care, ESS was founded just seven years ago.ESS relied on close and intensive cooper-ation with Siemens as a strategic partner for information and medical technology as well as in the building infrastructure area. While some Siemens business units were already involved in other ESS private hospitals and healthcare centers, numer-ous Siemens business units worked togeth-er at Hospital da Luz, including Siemens Enterprise Communications (SEN), Siemens Building Technologies (SBT), Industrial Solutions & Services (I&S), Automation & Drives (A&D), as well as Siemens Medical Solutions with its imaging modalities and Soarian® information technology (IT) and workflow management system. Soarian is the next generation of Siemens IT solutions that helps healthcare organizations to manage clinical, administrative, and finan-cial processes. Its key components include Soarian Clinicals, Soarian Departmentals, and Soarian Scheduling.

A Mammoth Project for Siemens

There was a reason behind it all: “Naturally, we could have looked to see which com-pany made the best offer in each area,” says Antão. But integrating numerous

companies in such a large project would add an increasing degree of complexity and risk, according to the CIO. Should prob-lems occur, it is better to only have to turn to one company. And often, systems or embedded processes from various companies do not articulate well.“For this reason, we looked for a partner who could offer not only a broad palette of products, but also a solution-oriented approach, and the best offer in this regard came from Siemens,” explains Antão.As a result, almost the entire infrastruc-ture of the 96,000-square-meter Hospital da Luz was installed by one of the Siemens business units, from the fire alarm and security system, to the lighting system, local area network (LAN) communication cables and the air conditioning system, to medical devices and IT. A mammoth project without comparison in the corpo-ration’s almost 100 years in Portugal. The cooperation with Siemens is the result of a “good, long-term partnership,” and can be explained by the new demands regarding modern private hospitals, accord-ing to Antão.Previously, private hospitals found their market niche through better food, nicer rooms, and shorter wait times. Today, however, that is not enough, says Antão. In the private sector, the infrastructure of hospitals and rehabilitation facilities has to meet ever increasing patient require-ments. “In addition to having the best medical and nursing staff, modern com-munications systems, state-of-the-art equipment, and innovative medical and information technology are playing an increasingly important role,” he explains.In order to gain recognition against other private hospital operators, one has to work with the best suppliers. “Especially

Digitized Hospital


when looking at the integration of vari-ous information technologies, Siemens appeared to be the only company with the corresponding capacity,” explains Antão.

Process Orientation Centered on the Patient

The IT, with solutions running from depart-mental systems, such as RIS/PACS (syngo® Suite), to an enterprise-wide electronic health record, implemented through Soarian, also played a major role in the decision to cooperate with Siemens. Today, Soarian supports care delivery processes

in more than 40 clinical specialties. One example is a diagnostic system for detect-ing sepsis, systemic inflammatory response syndrome (SIRS), and septic shock in patients. In principle, this pathological finding refers to out-of-control blood poi-soning or an infection that is extremely difficult to diagnose.Soarian is also linked to the HiMed Cockpit. Hospital Director Professor Jose Roquette says: “With Soarian and the HiMed Cockpit system, we can immediately access patient data and medical records anywhere in the hospital, even at the patient’s bed-side, simplifying work enormously.” He sees

the HiMed Cockpit linked to the Soarian system as trendsetting. It is not only avail-able to physicians and nurses, who call up patient data directly at the hospital bed using special chip cards, but the system also offers patients high levels of com-fort. “With their own hospital chip cards, patients can use the HiMed Cockpit to telephone, surf the Internet, watch TV, listen to the radio, order food or maga-zines online, or learn about their disease and treatment options from information we have entered into the system,” adds Roquette. Another example is the ongoing project to link the building management

Combining Soarian Health Information Management (HIM) and the HiMed Cockpit enables access to digital patient data directly at the bedside.

Digitized Hospital


Manuel Meyer reports from Spain and Portugal as a correspondent for the Austria Press Agency (APA).

system (Siemens DESIGO™) to the sched-uling systems: For example, if the air conditioning control system detects any deviations outside the normal scope, the respective operating room is not available to schedule procedures.As a private company, ESS must work cost-effectively and efficiently. In this regard, the modern communication systems from Siemens, as well as Soarian, help in stream-lining internal workflows and in eliminat-ing unnecessary work for all staff. The result: fast, patient-centered organization of work instead of siloed departmental thinking, Antão explains.This, in turn, results in shorter inpatient stays, better planning of ward workflows, less bureaucracy, and the elimination of expensive, unnecessary services, benefit-ing the hospital and its personnel, as well as the patients.

Portugal’s President Dedicates Hospital da Luz

Six months after opening in April 2007 is not enough time to make definitive state-ments regarding financial profitability or capacity and transaction numbers. The hospital first has to become known. But that should not be a problem: The public and the media are celebrating the hospi-tal as a symbol showing the way toward a new healthcare system. In April 2007, Portugal’s President, Cavaco Silva, was on hand to personally dedicate the country’s

Challenge:• One-stop solution for hospital

building technology, hospital and imaging equipment, and hospital IT

• Integrated approach to hospital IT

Solution:• Combining Siemens various

business units to match customers‘ demands

• Installation of Soarian as the core component of a clinical-oriented IT architecture

• Interfacing Soarian with Siemens IT solutions for facility management

Result:• All clinical specialities rely on

Soarian to support the care delivery process with an integrated view of patient clinical information, enabling them to center on patient care

• Hospital da Luz is an example of how private initiatives play an increasingly important role in the Portuguese healthcare system

most modern private hospital. Accom-panied by Portuguese Economics Minister Manuel Pinho and António Correia de Campos, the Minister of Health, Cavaco Silva explained at the dedication ceremony that Hospital da Luz is an example of how private initiatives would be playing an increasingly important role in the Portuguese healthcare system.

“With Soarian and the HiMed Cockpit system, we can immediately access patient data and medical records any-where in the hospital, even at the patient’s bedside.”

Jose Roquette, Director, Hospital da Luz, Lisbon, Portugal Summary

Further Information

www.siemens.com/healthcare

Image Management


Since the arrival of syngo Dynamics in their specialized cardiac facilities, two top children’s hospitals in the US Midwest have quickly moved to the cutting edge of image management and reporting technology. However, doctors at both institutions believe they have only scratched the surface of the benefi ts possible with this pioneering technology – in pediatric care and beyond.

By Ron French

Revolutions are not always noisy. Some begin with the boom of cannons and the clash of swords, but others occur with the click-clack of a keyboard.Thomas Forbes, MD, Director of the Cardiac Catheterization Laboratory, points his cursor at a name on a computer screen in the catheterization lab of Children’s Hospital of Michigan in Detroit. Not long ago, the lab had one system for image archiving and another for reporting. Today, with the click of a mouse, Forbes can display evidence-based reporting on cus-tomizable templates alongside embedded, high-clarity images. In the background, he can view autopopulated, hemodynamic variables. Another click, and Forbes can see images of previous cath procedures of the same patient. Another click, and the report can be sent to the billing depart-ment and to referring physicians in out-lying medical centers. “Revolution is a strong word,” says Forbes, “but syngo® Dynamics really has revolutionized how we work in the cath lab.”Three hundred miles to the west in Milwaukee, WI, Michele Frommelt, MD, examines a fetal echogram on a computer screen at the pediatric echo-cardiography laboratory of the Herma Heart Center at Children’s Hospital of Wisconsin, digitally

transferred from a hospital two hours away. Such studies used to be mailed or sent by courier. Reports would take days to be returned. “For our surgeons to be able to pull up a study almost instanta-neously and for people to get feedback right away is a dramatic change,” says Frommelt. “It helps us do our jobs better.”syngo® Dynamics is the multimodality image management and reporting system of Siemens syngo Suite, incorporating cine angiographic, echocardiographic, and computed tomography (CT) and magnetic resonance (MR) digital images and patient data into a flexible, evidence-based report. Since installing the system, two of the Midwest’s premier pediatric cardiology departments have increased their staff efficiency and patient throughput, while improving reporting accuracy through the interface of imaging and hemodynamics. And that may be just the beginning.

A New Rhythm in the Echo Lab

Children’s Hospital of Wisconsin is a 236-bed, state-of-the-art facility with a 4,000-person staff caring for more than 22,000 admissions a year. The facility was recently named one of the top ten chil-dren’s hospitals in the country by Child

Pediatric Cardiology Reporting Grows Up

magazine. The Herma Heart Center was rated the eighth best pediatric cardiology center in the USA, and it is easily one of the busiest. Drawing patients from a three-state area, the center performs about 750 surgeries, 450 catheterizations, and over 7,000 echocardiograms a year.“Echocardiography is the nerve center for everything that happens in pediatric cardiology,” says Peter Frommelt, MD, Director of the hospital’s Pediatric Echo-cardiography Laboratory. “It defines anatomy, physiology, and hemodynamics for all patients. It’s absolutely critical.”Quick and accurate reporting of echo studies is vital in pediatric cardiology, where each heart is as distinct as the snowflakes that fall past the windows of the Milwaukee hospital every winter. “Adults deal with coronary artery disease, and so the heart anatomy is almost always the same,” says Peter Frommelt. “In pedi-atric cardiology, no two hearts are the same. They all have different congenital abnormalities that require specialized imaging techniques to identify the abnor-malities, and specialized surgical tech-niques to correct them.”In the late 1990s, the center became the first pediatric echo lab in the nation to upgrade its archives from analog video-


tape to digital computer storage. The switch offered a dramatic improvement in the quality of archived studies, but that improvement stopped at the door of the lab. Reports made to referring physicians were still produced the way they had been for decades, in a multistep process that often took days. Final reports sometimes didn’t make it to the desks of referring physicians in surrounding cities for days. It was a frustrating half step forward. “If we know the information and nobody else does, it doesn’t help anybody,” says Peter Frommelt.In Detroit, doctors in the pediatric cardiac catheterization lab were facing a similar problem. Children’s Hospital of Michigan, part of the Detroit Medical Center com-plex, is the only freestanding children’s hospital in Michigan and the state’s lead-ing training center for pediatricians. The cardiac unit draws patients from around the world (five percent of its young patients are from other countries) for treatment by the unit’s 13 full-time phy-sicians and 70 employees. At the center

of the cardiac unit is one of the nation’s busiest pediatric catheterization labs, where about 700 procedures a year are performed.Until the arrival of syngo Dynamics, cath reports chewed up staff time. Doctors dictated two separate reports, both of which had to be transcribed and proofed. Hemodynamics written down during pro-cedures were later copied into reports. Images were copied onto various media. Finally, a thick packet would be sent by courier or mailed to a referring physician seven to ten business days after the pro-cedure.“About 60 percent of the time, the refer-ring physicians would see their patients back in their offices for follow-up exams before they got a dictated copy of the report,” says Thomas Forbes. Each report-ing step added time and reduced accuracy. Physicians were resigned to the system’s failings. “That’s just the way things worked,” Forbes says. “It’s kind of like type-writers. People say, ‘How did you ever use typewriters?’ But when that’s all you had,

you just did.” For Children’s Hospital of Wisconsin, the road to the Siemens sys-tem was long and bumpy. “We started out early with a vendor who provided digital archiving but didn’t have a good reporting tool,” Peter Frommelt says. “Then we went to a different vendor who didn’t even have a good image review system, let alone reporting. I knew from working with other people [at echo labs around the country] that Siemens had the Cadillac of review stations. I knew we’d be able to bring Siemens in and be able to review echo imaging seamlessly.”

Dramatic Timesaving Results

The hospital was able to transfer several years worth of archived digital images from the system of another vendor because syngo Dynamics is vendor-neutral – a huge relief for hospitals such as Wisconsin that are looking to switch systems. “The col-laboration has been very good,” says David Organ, IT Project Leader for Children’s Hospital of Wisconsin. “The tools we have that allow me to configure syngo Dynam-ics are far and away the best thing I’ve seen in the industry. With the last picture archiving and communication system (PACS) we had, every time I made a con-figuration change, I had to restart the server. With syngo Dynamics, I can just add devices as needed on the fly.”At about the same time, physicians at Children’s Hospital of Michigan were con-sidering three imaging systems and four reporting systems to outfit a new cath lab. “We ended up going with Siemens for both,” says Forbes. “They were committed to developing a pediatric cath lab, not only from an imaging standpoint, but also from a reporting standpoint. Most makers of cath labs gear them for adults – pediatrics is an afterthought. Siemens was much more forward-thinking in work-ing from the ground up.”syngo Dynamics allowed both hospitals to create evidence-based reports that included both notes and images for the first time. At Children’s Hospital of Michigan, the reports also included auto-populated hemodynamics.The results, while still early, have been dramatic. In Detroit, 20 percent* of the reports that used to take seven to ten days to reach referring physicians are now completed, archived, faxed, or e-mailed

Children’s Hospital of Wisconsin is a 236-bed, state-of-the-art facility with a 4,000-person staff caring for more than 22,000 admissions a year. On the right: David M. Organ (top), Dr. Peter Frommelt

Image Management


to referring physicians and sent to billing before the patient leaves the lab. All reports are completed within one day.Each lab has personalized the reporting templates to meet their needs. “Every-thing is here – patient history, the proce-dures, pressures, pictures – everything is templated,” says Forbes, clicking through a cath study in a room lined with com-puter monitors. “Angiograms used to be burned on a CD. It was problematic – no one had time for them. Now, the report is able to embed angiograms.”Dan Turner, MD, Assistant Professor of Pediatrics at Wayne State University in Detroit and one of the physicians in Children’s Hospital of Michigan’s cath lab, had reservations about the point-and-click system. “I wasn’t sure how user-friendly the system was going to be,” Turner says. “Dictation was easy for me. But now I can sit down between cases, do a couple of mouse clicks, and be done with a report in five minutes. It’s as close to real-time reporting as you can get. I’m spending less time doing all the chores we used to

Children’s Hospital of Michigan, part of the Detroit Medical Center, is the only freestanding children’s hospital in Michigan and the state’s leading training center for pediatricians. On the left: Paul Webster (top), Dr. Thomas Forbes

have, so there’s more time to do other things.”

The Ripple Benefi ts

In Milwaukee, the echo lab completed a study comparing the last month of trans-cription-based reporting to the syngo Dynamics-templated system. “Our median time went from 24 hours to about an hour-and-a-half,” Peter Frommelt says. “We don’t have to do anything but click a button. We’ve gotten tremendous feedback from physicians saying they really appreciate the speed of the reports – which really helps in their ability to deliver care quickly. Not only did patient and referring physi-cian satisfaction improve, but from a safety standpoint, I think it’s a real advance.”Doctors are spending less time generat-ing reports, giving them more time for patient care. Sonographers can complete echo studies faster. “The time from when a patient came into the room until a final study was completed went from 31 min-utes to 26 minutes. And that was despite

increasing the list of images they needed to capture to complete a study,” says Peter Frommelt. “We now take 85 different pic-tures just for a normal study.”Increasing throughput was a bonus that physicians at Children’s Hospital of Wis-consin did not expect. The echo lab direc-tor believes the standardized template “triggers in [staff] an ability to organize their thoughts more quickly. Our time is under tremendous demand. We were very happy to see our time to complete a study had gone down.”In Detroit, outside referring physicians are getting studies faster, and the studies they get are more thorough. “We used to do two reports, one for referring physi-cians and a longer report for archives,” Forbes says. “Now we do one report, and all the referring physicians prefer it – they get it all now, and it’s all done electroni-cally.”Efficiencies created by syngo Dynamics have freed up staff for other tasks. At Children’s Hospital of Michigan, one staff member used to spend 90 percent of

In Detroit, 20 percent* of the reports that used to take seven to ten days to reach referring physicians are now completed, archived, faxed, or e-mailed to referring physicians and sent to billing before the patient leaves the lab.

Image Management


Challenge:• Optimize communication

between regional hospitals and referring physicians

• Need for quick and accurate reporting in pediatric cardiology

• Large catchments area and busy cath lab demanding work-flow improvements

• Increase workflow efficiency, especially in the generation of cath lab reports

Solution:• Flexible, evidence-based reporting

on customizable templates with embedded, digital, high-clarity images

• Reports can include both notes and images, and can be completed, archived, faxed, or e-mailed within one day

• Immediate access to imaging studies and reports at diagnostic workstation

• Integrated patient digital imaging information

Result:• Time to generate a report

dramatically decreased• One-click access to reports and

ability to send to different departments and external parties

• Less time for reports, more time for patient care

• Revolutionary data research with improved verification, compliance and accuracy

Summary

her time transcribing dictation for cath reports. “Her original job has basically been eliminated by this,” Forbes says, “but it has allowed her to do other things for us in the cath lab.” Even the billing department has felt the ripple benefits of syngo Dynamics. Bills are not sent to insurance companies until a final report can be attached. Now, that can happen in hours instead of weeks.

Unlimited Potential

Doctors at Children’s Hospital of Wiscon-sin have noted improved consistency in reporting. “Each physician had his own style for describing a heart lesion in dicta-tion. With the templates, because every-thing is structured, everyone is reporting things in a more uniform way,” says Peter Frommelt. “There’s no question that for the referring physician, it’s easier to sort through the reports, because every report is set up in the same way.”Uniform reporting also provides a better defense in case of litigation, Forbes says. “We may take for granted certain proce-dures that we always do, and we may sometimes forget to dictate them. Some-times in the past, if you got busy, you may not have dictated for a day or two, and there was tremendous variation between physicians and even the same physicians doing the same procedure,” says Forbes. “This system has helped improve the reporting accuracy of all our procedures.”Both hospitals feel they are only beginning to realize the potential of the system. In Milwaukee, syngo Dynamics is driving referrals from outside hospitals and clinics. “Everybody has been happy with it – the physicians and the customers,” Organ says. “They can send studies through VPN

Efficiencies created by syngo Dynamics have freed up staff for other important tasks.

Increasing throughput was a bonus that physicians did not expect.

Ron French is an award-winning reporter for the Detroit News.

Further Information

www.siemens.com/syngo-suite

[virtual private network] connections with no loss of quality, and have our car-diologists read them immediately. If we make it easy for sites to bring us studies, volume will go up.”In Detroit, Forbes is excited about the research possibilities of the system. “It was difficult collecting data before,” he says. “This will revolutionize research. It helps improve verification, compliance, and accuracy.”Children’s Hospital of Michigan has had site visits from as far away as Australia looking at the Siemens imaging and reporting systems. “How happy am I with the system? I’m ecstatic!” says Lead Cath Lab Technologist Paul Webster, RT (R). “The Siemens collaboration has been seam-less,” Turner says, “There’s a lot more we can do with it. It grows with you. It’s really only limited by the user.“What is happening at Children’s Hospital of Wisconsin and Children’s Hospital of Michigan is so revolutionary that Peter Frommelt believes it will rewrite pediatric imaging standards. “I don’t think there is anyone out there who can tell you how long it should take for a finalized echo-cardiogram report to be available in an electronic medical report to the referring doctor,” he says. “But what we’ve found is that it shouldn’t be days – it can be hours.”

*Results may vary. Data on file.

Image Management


“How happy am I with the system? I’m ecstatic!” says Lead Cath Lab Tech Paul Webster, RT (R). “The Siemens collaboration has been seamless.”

MRI in Oncology


With syngo TimCT Oncology, the Department of Diagnostic Radiology at the University Hospital Freiburg uses a magnetic resonance procedure that leads to new clinical pathways: one MRI exam – the complete information. The new TimCT – Continuous Table move – application delivers excellent image quality and dramatically reduces the time to diagnosis.

By Sonja Böhm

“Suspected rectal cancer” reads the refer-ring diagnosis from the family physician which the patient brings to the Compre-hensive Cancer Center at the University Hospital Freiburg. Initially, matters proceed here as they do at many other clinics in Germany: The male patient undergoes a physical examination and is then admitted to the radiology department, where the tumor region is examined using high-resolution magnetic resonance imaging (MRI) – currently the best imaging pro-cedure for displaying the local extent of advanced rectal cancer.

Tumor Localization with Continuous Table Move MRI

But Freiburg has something special: The stationary, high-resolution MRI for primary diagnosis of the tumor is supplemented – during the same examination – by a continuous table move MRI measurement. The patient slowly slides through the magnet tunnel on a continously moving table, so that the chest and abdomen can be examined using TimCT (Continuous Table move powered by Tim®) acquisition. “The liver and lungs are the two organs of greatest interest to us,” explains Arnd-Oliver Schäfer, MD, Assistant Professor and Head of the Clinical MRI section. “We know that every fifth patient with rectal cancer develops liver metastases, and every 12th, pulmonary metastases.”“The primary diagnostic procedure, the high-resolution examination of the tumor,

is critical for planning surgery,” adds Pro-fessor Mathias Langer, MD, MBA, Chairman and Medical Director of the Department of Diagnostic Radiology at the University Hospital Freiburg. “Naturally, however, it is also important to know whether it has metastasized and to which extent the primary tumor has spread. Depending on this information, the selection of the most appropriate therapy can be done prior to surgery.”After about a 20-minute examination in Freiburg, the findings are complete – how the tumor looks, how it has expanded locally, and whether it has metastasized. “In other hospitals, you go to an MRI exam after the primary diagnosis of the tumor. Then, you go to the next examination appointment and undergo a computed tomography [CT] scan of the upper abdo-men and maybe a sonogram. And then, during another appointment, a CT scan of the thorax is performed,” explains Profes-sor Langer as he describes the usual pro-cedure. “If you’re lucky, the examinations are performed three days in a row; if you’re not, it can take three weeks!”

Accurate Therapy Planning

In Freiburg, MRI is performed after recto-scopy and biopsy, where a sample is taken for the histological examination. “We can perform part of the tumor characteriza-tion using MRI,” says Langer. “The various image impressions that can be obtained in magnetic resonance imaging by using

Speeding up Clinical Workfl ow in Cancer Staging

special protocols of the same slice allow for greater differentiation of the disease – we do more than verify the tumor, we are very specific about it,” he says as he explains the additional benefits of syngo® TimCT MRI technology – “MRI thus pro-vides us with much more information.”The patient’s images and diagnostic find-ings are subsequently discussed at the interdisciplinary tumor conference. “Nor-mally, no more than a week passes from the time the patient first comes to the hospital until the tumor conference – at that time everything is available and at the next appointment, the patient receives a therapy plan.“ The plan already includes, for example, how to proceed after surgery and therapy – follow-up examinations with MRI are also a critical part of after-care. “MRI is an excellent way to gain an indication of recurrence or metastases, often at a time when the patient subjec-tively feels completely healthy,” says Professor Langer. “Because we perform the same examination repeatedly using a standardized protocol, we are in a good position to compare the images,” adds Schäfer. “Through semiannual examina-tions, we can detect metastases at an early stage – at a time when they may be resected with curative intent.”

One MRI Examination – Maximum Information

Clearly, both the patient and hospital benefit from the new so-called T-class MRI

Movement is what it is all about: Dr. Schäfer on his way to an MRI exam (above); diagnostic work-up of a rectal cancer patient using three Tim matrix coils (below).

MRI in Oncology


generation with syngo TimCT. Multiple schedulings are replaced by only one MRI scheduling. This significantly improves hospital workflow. Time and resources are saved and communication is simplified. After only one examination, the patient obtains a fast diagnosis, enabling optimum therapy planning.“Various examinations during different appointments, where diagnostic findings have to be communicated to various clini-cal colleagues – there is always the risk of a loss of information,” says Professor Langer. “Here, the oncologist, gastroenter-ologist, surgeon, and radiotherapist get the information they need from a single examination.”Additionally, because two different types of images are used in localizing metastases – a fluid-sensitive one for bone marrow infiltration and pulmonary lesions, and a second one acquired in a breath-hold using contrast to localize liver metastases – the vascular display is provided to the surgeon. “We now have what we always dreamed of: all the necessary diagnostic information in only one single examination.”

An Overview Image and many “Magnifying Glasses”

Conventional MRI systems allow for measurements of body regions up to 50 centimeters. Such a measurement is well suited for primary diagnosis of the tumor when its approximate location is known.

However, to cover larger areas, such as when localizing metastases, the patient and coil have to be repositioned for each measurement, which makes for very time-consuming examinations. In addition, slice images generated in this step-by-step manner have to be first composed on the computer before they can be diagnosed.The syngo TimCT procedure used in Frei-burg has solved this problem with a revo-lutionary technique. Tim stands for ’Total imaging matrix’ – a unique coil concept from Siemens.Professor Langer explains the innovative technology: “Tim is a way to perform a high-resolution examination of the entire body using MRI. First, a large magnetic field is generated using a large coil – this produces an overview image much like Google™ Earth – the earth from above. Then we take magnifying glasses, in this case special coils, in which we wrap the patient from head to toe. This enables us to view every part of the body magnified, without having to reposition the patient. Optimum resolution is always provided – even down to the smallest structures. Now with TimCT, the whole concept is taken to the next level. TimCT examinations compared to conventional MRIs show a dramatic change – similar to that from climbing a ladder step-by-step to taking the elevator. The table in the TimCT MRI examination now moves continuously, just like in CT, hence the name TimCT. This dramatically simplifies workflow and

Challenge:• Several exams, modalities,

and associated rescheduling needed for evaluating the primary tumor and localizing metastases

Solution:• syngo TimCT – Continuous

Table move powered by Tim (Total imaging matrix) technology

Result:• Complete diagnostic informa-

tion (primary tumor evaluation, localization of metastases, and detailed anatomy) available after only one MRI exam

Summary

“Here, the oncologist, gastroenterologist, surgeon, and

radiotherapist get the information they need from a

single examination.”

Professor Mathias Langer, MD, Medical Director, Department of Diagnostic Radiology,

University Hospital Freiburg, Germany

MRI in Oncology


improves patient comfort – while deliver-ing excellent clinical image quality, as shown by our experience.”

Seamless Examination in only Six Minutes

During the examination, the patient slowly passes through the scanner at a speed of one centimeter per second. He is covered by the special coils and positioned on the continuously moving table, similar to a CT system. Normally, the acquisition qual-ity in MRI suffers from movement. How-ever, since several coils can be activated simultaneously with Tim, fast measure-ments across a broad area are possible due to parallel imaging. This ‘Multislice Acqui-sition’ is a critical requirement in order to perform measurements with continuous table movement.The system’s software reconstructs images in a way that eliminates motion arti-facts due to, for example, breathing. “As a result, the entire patient is examined seamlessly, and all in about six minutes.” The innovative coil concept, according to Schäfer, ensures that images are acquired at the magnet‘s isocenter. “For that reason alone, the measurement quality is excellent.“

A Dream Comes True

Professor Langer is proud that his team in Radiology together with the Department of Medical Physics under Professor Jürgen Hennig, PhD, Scientific Director of the Department of Diagnostic Radiology, Medical Physics, has developed the MRI procedure together with Siemens and their other collaborators. At the end of 2005, the procedure was tested on the first patient cohorts. “Professor Hennig and I have dreamed of whole-body exam-inations with MRI since the early ’90s – we were both convinced it had to be pos-sible somehow.” The rapid development of computed technology provided the critical prerequisite. “It gave us fast com-puters capable of quickly processing large quantities of data produced per unit of time.” And so it happened that the wish of the physician and the dream of the physicist became a reality.In the meantime, several thousand exam-inations have been performed in Freiburg with the new technology. About 1,500 of these examinations were for rectal car-

cinoma, the most convincing application field of syngo TimCT technology in oncol-ogy.Naturally, MRI can be used to localize tumors and metastases of other types of cancer. These include breast and bron-chial, prostate and pancreatic cancers, as well as the display of skeletal tumors and lymphoma.

“Not an indication today for which it can’t be used!”

The various advantages of MRI, such as excellent soft-tissue contrast, no radiation exposure, and good detail resolution, mean that the procedure is of interest for a variety of indications. In Freiburg, the procedure is additionally being used for

diagnostic work-up of patients with recurrent Crohn‘s Disease. Using contrast agents, inflammations of the intestinal wall are displayed well in MRI. The charac-teristics of the inflammation, involvement of the surrounding tissue, and complica-tions such as fistulas, abscesses, and ste-noses, are all well differentiated, explains Professor Langer.Additional indications for the syngo TimCT technology include whole body imaging of the vascular system and inflammatory muscular diseases. Professor Langer: “With the exception of MRI, there is no procedure that can display a per-son’s entire muscular system and localize inflammations. There is not an indication today for which it can’t be used.”“In three years, we may well be perform-ing the entire spectrum with a moving table, where today the examination is stationary,” adds Dr. Schäfer. He has great hopes for diffusion-weighted imaging: “This enables better characterization of tumors, and will simplify their differentia-tion.“Professor Langer says, “TimCT Oncology represents a cutting-edge technology for cancer staging with whole-body MRI and has the potential to dramatically improve patient workflow. We just love it!”

After completing her biology and chemistry studies in Heidelberg, Sonja Böhm worked for many years as a medical editor. She has worked as a freelancer since 1997 and regularly con-tributes to numerous health and medical media, and edits professional journals.

Further Informationwww.siemens.com/MAGNETOM-Special-2006

“The entire patient is exam-ined seamlessly, and all in about six minutes.”

Arnd-Oliver Schäfer, MD, Department of Diagnostic Radiology, University Hospital Freiburg, Germany

Therapy Control


Imaging is becoming a popular instrument across all areas of disease management – from initial diagnostic fi ndings to therapy control. Take cancer, for example: After diagnosis, images acquired later show whether the tumor was treated successfully or has recurred. This information, supported by new software tools, determines subsequent procedures.

By David Tenenbaum and Hildegard Kaulen, PhD

Cancer Monitoring: Find – Fight – Follow

Therapy Control


With the new software, automated comparison of tumor burden, growth or shrinkage becomes more precise.

With syngo® CT Oncology and syngo TrueD, Siemens Medical Solutions devel-oped two valuable software packages for monitoring cancer. syngo CT Oncology includes set algorithms for the segmenta-tion of lesions in the liver, lungs, lymph nodes, and other regions of the body in computed tomography (CT) images. The software calculates various tumor para-meters and compares them with subse-quent diagnostic findings. As a result, tumor burden, growth parameters, and

Challenge:• Increasing amount of data

produced by medical imaging• Difficulty to compare primary

and follow-up studies for judging treatment response in oncology

• Different criteria for measuring treatment response (RECIST, WHO)

• Measuring and comparing studies are time-consuming processes

Solution:• Automated follow-up with

syngo TrueD (for PET·CT) and syngo CT Oncology (for CT)

Result:• Software enables comparison of

changes in metabolic activity as well as tumor burden, growth or shrinkage

• Studies are planned to evaluate tumor volume as criterion for treatment response

Summary

other values can be tracked. syngo TrueD was developed for hybrid imaging using positron emission tomography-computed tomography (PET·CT) or single photon emission computed tomography-computed tomography (SPECT·CT). As a result, data sets from PET·CT examina-tions acquired at two or three time points are automatically registered for an on-screen comparison. Leading cancer centers are working with these two software tools.

Therapy Control


Before data becomes information, it must be thoroughly examined and analyzed. As computed tomography (CT) scanners produce a growing torrent of data, radiol-ogists confront a data-or-information ques-tion every day: how to obtain the maxi-mum patient benefit from the hundreds of slices that an advanced CT scanner pro-duces from each patient scan? Rigorous, accurate, and repeatable analysis of CT scans is a matter of life and death in oncology, but the sheer quantity of data raises the potential for operator fatigue and even error, and it also raises work-flow headaches at the management level.All of these hazards are multiplied by the regular follow-up studies needed to track

tumor response to treatment. But wading through data is precisely why computers were invented. Several years ago, Siemens CT applications gained the capability to automatically detect tumors. Now, the new syngo® CT Oncology software has the capability to automate lesion measure-ment, routinely calculate tumor volume, and support a wide range of the data-handling operations necessary for top-flight medical care.

Quick, Accurate, and Consistent

In preliminary tests, Vahid Yaghmai, MD, Associate Professor of Radiology at the Northwestern University Feinberg School

of Medicine in Chicago, IL, USA, says this new software matches the best human measurements: “In our experience, we have seen an excellent correspondence between a manual measurement of lymph node tumors and most liver tumors, and the automatic software measurement. It’s very quick, accurate and consistent in measuring lesions using the RECIST [Response Evaluation Criteria in Solid Tumors] and WHO [World Health Organi-zation] standards.” Yaghmai is also Medical Director of CT at Northwestern Memorial Hospital – Northwestern University, a tertiary care hospital in Chicago with one of the largest oncology units in the United States. In May 2007, he reported to the American Roentgen Ray Society that man-ual and automatic segmentation and mea-surement of abdominal and pelvic lymph nodes corresponded closely, according to both RECIST and WHO criteria. Similarly, he reported to the Society of Gastrointes-

Let the Computer Do It: Fully Automated Tumor Tracking

“The new syngo CT Oncology soft-ware is a much faster way of comparing and analyzing data.”

Vahid Yaghmai, MD,Associate Professor of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA

Therapy Control


tinal Radiologists that the software success-fully segmented and measured 22 liver lesions on contrast-enhanced CT scans from 12 patients.

Simplifi ed Follow-ups

Another key advantage of syngo CT Oncol-ogy is evident in its many improvements in throughput and workflow. To obtain automated measurements from syngo CT Oncology, a radiologist clicks on the lesion on the display and immediately receives a readout of x, y, and z dimensions, RECIST and WHO measurements, and lesion volume. Flexibility is the key to syngo CT Oncology software, and Yaghmai stresses that it does not take decisions out of the doctor’s hands, but rather allows the physician to use preferred measurement standards. “The software can segment out the tumor and correctly measure it, pro-viding RECIST, WHO and volumetric data

– so the doctor can use whichever he or she wants.”A further advantage is ease of follow-up. “The software is capable of comparing previous measurements with new mea-surements,” says Yaghmai. “It’s a much faster way of comparing and analyzing data.” On follow-up scans, the system dis-plays previous data on the same lesion, and calculates any dimensional change during the interim. “In a large oncology center, measuring lymph nodes in multiple dimensions and reporting on multiple lesions in every study is a very time-con-suming process,” says Yaghmai. “An auto-mated way of measuring lesions would really improve workflow. You decide which lesions to evaluate, and click on as many as you want. Theoretically, somebody who is not a radiologist can look at those lesions on a follow-up study.” This simpli-fied follow-up is one of the most signifi-cant benefits of this new syngo software;

there is no need to ’find‘ the same tumor on previous images and then determine which slice shows the greatest single dimension for RECIST or WHO measure-ments – those repetitive functions are now all embedded in the software. “When you follow patients based on these measure-ments, you want consistent and reliable data, and this software provides it. It virtually eliminates human error and the variations in measurement that can occur when doing it manually,” says Yaghmai. “Despite advances in technology, consis-tency remains a problem in radiology. There have been many studies showing that measurements of the same lesion by two observers will be different. syngo CT Oncology eliminates that part of the inconsistency.” This improvement may be particularly important in irregular tumors with poorly defined margins that are dif-ficult to measure.

Better Patient Care

On the practical level, automated mea-surement can also improve the accuracy of comparisons when patients change hospitals. “Many patients are first imaged at a small community hospital,” says Yaghmai. “The National Cancer Institute is pushing for us to standardize the way we follow up tumors. There really is a lot of variability in how different centers do follow-ups, and we want to standardize how we acquire images and measure these tumors. Automated measurement can also advance the state of the art in oncology by improving the accuracy of tumor assessment during clinical trials.” Greater accuracy may also help resolve long-standing questions about the rela-tive value of RECIST and WHO standards. Most of the debate stems from the issue of human error in manual segmentations.syngo CT Oncology also addresses a key issue in radiology: fatigue. “Operator fatigue is always a huge issue in radio-logy,” says Yaghmai, “especially with the increasing number of slices – from several hundred to a thousand per study. Fatigue has a lot to do with it. And there, the num-

Therapy Control


ber of CT scans obtained in large centers like ours is increasing.”

Volume as a Standard Modality?

Fast, accurate, and repeatable tumor seg-mentation and measurement are signifi-cant advances, but syngo’s new ability to automatically calculate tumor volume could have equal importance. Studies have already shown that the volume of lung tumors may be valuable for assessing progression or regression; similar studies for liver, bone and brain tumors remain to be completed. Although the role of vol-ume in determining tumor status remains subject to further research, “Intuitively, we think it should be important,” says Yaghmai. “But until now, the difficulty of performing volume measurements has limited our ability to validate this.“In the longer term, automated tumor measurement can take radiology firmly into the third dimension. While each com-ponent of a CT scan is a two-dimensional slice of the patient’s anatomy, tumors themselves are three-dimensional objects, and the newfound ability to automatically measure volume will allow comparisons to see whether volume, RECIST or WHO is most appropriate for evaluating treatment. Volume is a particularly difficult issue in

small lesions, which are difficult to mea-sure manually, and where a slight error in measurement can lead to a significant error in volume calculations. “When you measure a small tumor manually, because it is less spherical and has more irregular margins, the measurement will be more prone to error,” says Yaghmai. “Since the software can segment out lesions that are quite small, you eliminate that variability,” he explains, adding that furthermore, some studies indicate that as a tumor gets smaller, volume should play a more im-portant role in follow-up. Here, too, auto-mated measurement may provide an im-provement in accuracy.Although the exact implications of vol-ume measurements in terms of patient management for tumors of the liver or lymph nodes remains to be seen, Yaghmai stresses that accuracy and repeatability have immense value in improving patient care. “We do not want the human factor to be a component of these measure-ments,” he says. “It’s better for the patient to have realistic information. Whether or not volume becomes a standard modality for evaluating treatment, software like this will eventually be standard for any follow-up of oncology patients. Previously, the technology was not available, but now it is.”

Master of Comparison in Hybrid Imaging In PET·CT (positron emission tomography-computed tomography), metabolic images are superimposed on anatomical images. Using this hybrid-imaging method, tumors are no longer detected merely by appear-ance, but through their metabolism as well. Using the syngo® TrueD software package, hybrid images acquired over a period of time can be compared and quan-tified on a display for the first time. Medical Solutions spoke with Professor Bernd Joachim Krause, MD, of the Univer-sity Hospital Rechts der Isar in Munich, and Andreas Wahl, MD, of the PET·CT Center in Hamburg, Germany, regarding its clinical potential.

Dr. Wahl, you are a nuclear physician and radiologist in private practice. In your opinion, what is unique about syngo TrueD?WAHL: The uniqueness of syngo TrueD is its ability to work with the large volumes of data associated with hybrid imaging while simultaneously providing a com-parison mode. This integrated combination was not previously available. Either one or the other was possible. Using syngo TrueD, six data sets can be loaded – three CT scans and three PET examinations. We are now able to establish a direct relation-ship between images acquired at different points in time even from a quantitative

view. The software package provides a range of flexible screen layouts and tools. Automatic registration takes less than half a minute. This improves our workflow by reducing the time for handling and evalu-ating image data, helping the physician to focus on the relevant findings.

How do patients benefit from the comparison mode?WAHL: Both accuracy and reproducibility in diagnosis as well as measurement com-parisons are improved with using a soft-ware with specialized tools like syngo TrueD. And this is possible irrespective of whether standardized criteria such as

Left: Professor Bernd Joachim Krause, MD Right: Andreas Wahl, MD


“This is the reason why PET·CT is so important in oncology, because we learn something about both function and structure.”

Professor Bernd Joachim Krause, MD,Senior Physician, Technical University, Hospital Rechts der Isar, Munich, Germany

metabolic activity – calculated as Standard-ized Uptake Value (SUV) – longimetry according to WHO [World Health Organi-zation]/RECIST [Response Evaluation Crite-ria in Solid Tumors] standards or measure-ments are being applied. The patient benefits from a precise calculation of response after chemo- or radiotherapy, for example, by means of elimination of technical errors that could otherwise cause an inadequate treatment. Addition-ally, the software package supports fusion with other images. This includes magnetic resonance, CT, PET, or SPECT [single photon emission computed tomography] images acquired at other facilities. This is

Therapy Control


“We are now able to establish a direct relationship between images acquired

at different points in time even from a quantitative view.”

Andreas Wahl, MD,Nuclear Physician and Radiologist,

PET·CT-Center, Hamburg, Germany

also of significant benefit, because com-parison of the present PET·CT with these former (external) examinations is neces-sary for a correct diagnosis.

Professor Krause, you work at the University Hospital and also keep an eye on clinical studies. Where do you see the benefits of syngo TrueD?KRAUSE: In recent years, we have seen that cancer is a heterogeneous disease. Individualized therapies are a main goal in the future. You may ask what that has to do with syngo TrueD. Allow me to explain. To develop individualized therapies, we need comprehensive information regard-ing their effect. Morphology alone is no longer sufficient. This is the reason why PET·CT is so important in oncology, because we learn something about both function and structure. For therapy con-trol, we therefore have a great need for new criteria that allow assessment of therapy response – so-called surrogate parameters. To date, the primary orienta-tion has been toward the diameter of the tumor lesion. But metabolic activity may be a much better surrogate parameter, especially if correlated with volumetric information, and if a fast comparison of two examinations over time is available for hybrid imaging. We gain sophisticated information and a completely different method of access to the timeline of a treat-ment. The task before us is very clear: We have to find reliable thresholds for

the segmentation of tumor lesions and changes of metabolic activity. That is, we have to see which grayscale values securely delineate the boundaries of a tumor or which percentage change in glucose metabolism indicates therapy response, and then create clinical studies that establish volume and metabolic val-ues as surrogate parameters.

How has the response to radiation and chemotherapy been determined to date? Is diameter the only recognized surrogate parameter?WAHL: WHO and RECIST criteria are estab-lished and can be used predominantly for solid, well-definable lesions with a minimum size.Those criteria are based on two-dimensional [WHO] or one-dimen-sional [RECIST] measurings in axial CT images. But applying those criteria to lesions that are hardly definable or very small is problematic and can easily involve relevant measuring inaccuracies. For tumors like GIST [gastrointestinal stromal tumor], which can increase in size during therapy, they cannot reliably evaluate

therapy response. In principle, a calcula-tion of tumor volume by means of multi-slice spiral CT and the respective software algorithm is possible in much more detail. Functional information, for example from PET studies, is not considered in these criteria, although for some diseases [M. Hodgkin’s, DLBCL-NHL], evaluation of therapy response would be helpful to them.

KRAUSE: The RECIST and WHO criteria have clear limits, as have been shown time and again. In addition, they are from a time when slice imaging procedures were not at the standard we have today. And we have gone a step further with hybrid imaging. What we lack now are clinical studies that show the value for the clinical routine of metabolism, volume or another surrogate parameter. Here, one can see clearly how development proceeds. First, the technical prerequisites are established. Then, clinical potential is investigated. I am absolutely convinced we will have dif-ferent surrogate parameters for various tumor entities in the future. Volume will

Therapy Control


David Tenenbaum is a freelance science, medi-cal, and technology journalist based in Madison, WI, USA. He is also the head writer for The Why Files, an electronic magazine covering “the science behind the news,” which was started in 1996 by the National Science Foundation and the University of Wisconsin.

Hildegard Kaulen, PhD, is a molecular biologist. After positions at Rockefeller University in New York and Harvard Medical School in Boston, MA, USA, she has worked since the mid 1990s as a freelance science journalist for well-known news-papers and scientific journals.

merely be one of many. In addition to maximum length and volume, other con-ceivable parameters include density, metabolism, and surface characteristics of a lesion for example.

Professor Krause, have you already planned concrete studies to show whether, besides metabolism, the volume of a tumor is a good surrogate parameter for therapy response as well?KRAUSE: Yes, we have created a study to examine whether, using a combination of thresholds for metabolism with volu-metric variables (among others, segmen-tation-based volumetry), achieves an even better prediction of tumor response to a therapy. We hope to see how close we come to reality with the software. I am excited!

In Germany, PET and PET·CT fall under private physician or individualized healthcare services, the only excep-tions being staging, restaging, and follow-up for non-small cell lung cancer.

“Individualized therapies are a main goal in the future.”

Professor Bernd Joachim Krause, MD, Senior Physician, Technical University, Hospital Rechts der Isar, Munich, Germany

Their in-patient use is still difficult due to financial restrictions. What do you think about this situation?WAHL: Approval of FDG-[18F-fluorodeoxy-glucose-]PET for non-small cell lung cancer shows that its significance for oncology can no longer be negated. But presently, long consulting processes for this indica-tion make prognoses for the approval of further indications difficult. However, with new modes of care in public health insur-ance, PET diagnostics may be established at least on a regional level.

KRAUSE: In Germany, we are dealing very cautiously with the potential of hybrid imaging because it does not have its own distinct billing codes, whereas in most other European countries, there is a gen-eral cost reimbursement. Fortunately, a change has been made in cost reimburse-ment for non-small cell lung cancer. However, we have another problem in Germany, that of positron emitters. Only 18F-fluoro-desoxyglucose – marked glucose – is approved. The use of other markers is difficult due to the German

Further Information

www.siemens.com/ct-oncology www.siemens.com/TrueD

Pharmaceutical Act. Positron emitters have to be approved as pharmaceuticals. I expect there will be a simplified approval process soon. Given the potential of hybrid imaging and the new capabilities provided by software packages such as syngo TrueD, that would be very desirable.

Radiology Workfl ow


In 2004, Jameson Health System in New Castle was the fi rst medical center in the USA to implement Siemens syngo Suite in its Department of Radiology. Jane Beight, Administrative Director of Medical Imaging, and Albert J. Cook II, MD, Medical Director of Radiology, worked closely with Siemens in the beta testing of this unique archiving and reporting tool.

By Robert L. Bard

In an effort to increase efficiency in its Radiology Department, Jameson Health System, Inc., chose to implement the syngo® Suite system. This solution includes syngo Workflow (radiology information system – RIS), syngo Imaging (picture archiving and communication system – PACS) and syngo Portal Radiologist, the role-based interface that helps streamline radiologists‘ tasks in a simple, organized way. The comprehensive solution proved to be extremely beneficial in all aspects of radiology.Because the hospital performs more than 100,000 radiological examinations each year, implementation of syngo Suite

required detailed planning. Radiology Department Director Jane Beight knew that the first six months would be challeng-ing, because she would be redefining the way the department operated. And she was right: The entire department rede-signed its workflow, and Beight educated the staff members about their new roles. Despite the challenge of organizing work spaces, designing workflow, and install-ing new computers, Beight states that the largest hurdle was staff education and workflow changes – not technology.Jameson Health System is located in rural Western Pennsylvania, where, until re-cently, there were many physicians who

Jameson Health System provides care to citizens of New Castle in Western Pennsylvania.

Enhancing Radiology Workflow

syngo Suite quickly became Dr. Cook‘s favorite RIS system because of the concise way it displays information and its voice recognition system – which he considers to be the best.

Radiology Workfl ow


had never used a PACS to view images. The majority of them still relied on film to evaluate each case, and paper to docu-ment their findings. Computer education and workflow design were required for all physicians. Within a week of being intro-duced to syngo, the radiologists became comfortable using the basic functions and were interested in learning its more advanced applications. The more familiar the physicians became with syngo, the more valuable the system became to their workflow. The instantaneous report generation motivated the physicians to learn more because they experienced a multitude of benefits to workflow and patient care. A small amount of training time and effort were required to learn the basic tasks associated with the integrated RIS/PACS system. “With a little education

and familiarity, the new user can easily become comfortable using the system and becomes a strong supporter of it,” Beight adds. “The benefits it brings – particularly the decreased turnaround time – have made believers of even skeptical clini-cians.”Making the transition to the syngo Suite system has been made easier because of its familiar Siemens design. Many radiolo-gists at Jameson have prior experience with a Siemens imaging modality and the user interface, and menu styles of the PACS and RIS are consistent across the Siemens product line.

A New Voice for Radiologists

When Jameson Health System identified a need for a PACS, it assembled a special leadership team to evaluate the different

companies, services, and packages avail-able. Beight says that Jameson chose syngo Suite because the physicians and administrators saw the benefits of having an integrated system for all imaging and information. As Beight comments, “Siemens is a valuable collaborator in our information technology. They aggressively seek input from users in an attempt to satisfy their customers and to improve their products.”Dr. Cook has experience with four other RIS solutions, and he states that syngo Suite is his favorite because of how the information is presented with syngo Portal Radiologist. “Everything is very com-pact and very logical, and it’s all on the screen at once, including prior reports. There is no need to open a bunch of windows on a screen and have to guess

which window you are working with. It is very user friendly for me. syngo also has the best voice recognition system.” Dr. Cook has found that the voice recog-nition system cuts down on reporting time, especially when incorporating the ’normals’ template.The voice recognition system was initially a concern for some of the radiologists, but these concerns were quickly dispersed. The system easily adapts to individuals of different ethnicities and dialects. Dr. Cook believes the voice recognition system plays a big part in the ability to improve efficiency. With syngo Voice, Jameson has downsized its medical transcription needs, decreasing from five full-time employees to about three. The need for medical transcription has diminished considerably, because physicians self-edit the final reports from their own established tem-

From image acquisition to image display, diagnosis, and voice recognition for reporting, syngo Suite supports the radiologic process.

Radiology Workfl ow


plates, which they have become very accustomed to using.As a complement to all the electronic information necessary for the radiologists to read, Jameson has incorporated a digi-tal scanner that enables them to have all information electronically. This comple-mentary tool enables paper documents, such as prescriptions, to be scanned in as part of the electronic record. Jameson has found that scanning saves considerable amounts of time and effort while it de-creases the likelihood of a typing error.

Turnaround Time Cut in Half

Both Beight and Cook applaud the bene-fits of a more efficient workplace with syngo. Turnaround time was about 24 hours before syngo Suite was implemented,

starting from the time the patient com-pleted a test to the time the radiologist signed off on the final report. Since syngo Suite has been implemented, the turn-around has been cut in half to approxi-mately 12 to 14 hours. Cook adds: “syngo Suite has enabled the clinical process to be moved forward 12 hours, which has improved both clinical decision-making and patient satisfaction. We don’t have to review and re-review cases anymore, so the medical staff gets the report they need from us much more quickly than before. We also don’t have to dig through and try to find things now. Everything we need to interpret studies is available to us in a compact, logical format.”Such a timely report is even available with less effort from both the radiologist and support staff. As Beight notes, “Before syngo Suite was implemented, we incurred

the risk of misplacing patient studies, which required extra effort to retrieve. With syngo Imaging, we find less studies being misplaced.” With the results imme-diately available on a computer file or even via the Internet, staff members are not required to file and retrieve films at several different locations. The clinic staff no longer scrambles to search for missing test results or films; clinics run smoother and the staff concentrates on providing quality patient care. Jameson used to have file clerks whose primary responsibilities were to move films from one location to another. The PACS eliminated the need to move large, bulky films to many different places and the need for space to store these films. “Our film budget has been reduced by over 80 percent in our first year because we are no longer paying for hard

copy pieces of film and the chemistries and maintenance for the developing pro-cess,” says Beight. “These savings have helped offset the costs associated with implementing the PACS.”Jameson Health System has also reaped financial benefits that are difficult to quantify since implementing syngo Suite. Beight identifies the radiologist as the most expensive resource, and syngo has helped to make it easier to keep radiolo-gists efficient because they are provided with an easily sorted task list, and their time and energy is spent interpreting im-ages. Dr. Cook echoes Beight’s sentiments. “I am spending more time reading images and less time manipulating the computer, and that is important to me,” he says. “Siemens has helped to make it as easy as you can to provide more opportunities to read images and improve patient care.”

The server and IT backbone work in the background, unnoticed by the user.

Single sign-on across syngo Suite

syngo Portal Radiologist displays scheduled procedures each day.

Common syngo user interface

Radiology Workfl ow


Robert L. Bard is a freelance medical writer certified by the American Medical Writer’s Associ-ation who also conducts clinical research at the University of Michigan’s Division of Cardiovascular Medicine.

Challenge:• Improve workflow and image

management in the radiology department

Solution:• Installation of syngo Suite, which

includes syngo Workflow, syngo Portal Radiologist with syngo Voice, and syngo Imaging

• Installation of document scanner to replace paper documents

Result:• Reduced report turnaround time

from 24 to 12 hours• Reduced number of misplaced

patient studies to nearly zero• Reduced number of transcription-

ists from five to three• Reduced number of typing errors• Reduced money spent on films by

over 80 percent• Physicians are able to spend

more time reading patient images and delivering patient care

• Avoidance of repeated exams• Increased patient and referrer

satisfaction

Summary

Further Information

www.siemens.com/syngo-suite

“Siemens is a valuable collaborator in our information technology.”

Jane Beight, Administrative Director, Medical Imaging, Jameson Health System, New Castle, PA, USA

Patient satisfaction is improved because of more efficient processes. Patients are no longer repeating studies that have been misplaced, and referring physicians are no longer making excuses as to why a study is missing or has yet to be inter-preted. The electronic format has given the patient more control. Some centers give patients their own electronic copy of their tests on a CD, and their referring physician can access the test results via the CD or the Internet. Some interested patients even access the files themselves, because the CDs include a free DICOM reader. Beight states that syngo Suite has improved patient care, “Because we are able to get the right information to the right people at the right time.”

Redefi ning Workfl ow

Getting the information to the right people has helped the clinic areas and other hospital departments at Jameson Health System operate more efficiently. Allowing images to be reviewed at multiple loca-tions at once significantly improves work-flow efficiency.Such organization has also improved how consultations are performed. With syngo Suite, the referring physicians can access the digital images directly from their prac-tice. Groups of physicians do not have to arrange their schedules and meet at one particular location to discuss a case. With syngo Suite, an infinite number of review-ers can look at the case from any location where a computer and Internet access is

available. Many physicians like the system because the images are presented in the same manner at their home on the Inter-net that they are accustomed to at their office workstation.The implementation of syngo Suite has truly redefined the entire workflow struc-ture at Jameson Health System. After many discussions with RIS managers at different medical centers and personally researching different PACS and RIS systems, Beight concludes: “The first six months of implementation were very demanding, but since the system has been up and stable, we’ve been very sat-isfied.” Dr. Cook agrees with Beight and offers a ringing endorsement of syngo Suite by stating: “If I have to read a case, I would much rather read it on the syngo Suite system.“

Facility Planning


Susquehanna Health’s Cancer Center breaks the boundaries of its physical location to capture ambient daylight, improve the patient experience, and, ultimately, offer the kind of workfl ow effi ciency that promotes operational and personal well-being.

By Karen Schweizer

Nestled between a branch of the Sus-quehanna River and the base of Bald Eagle Mountain, Williamsport, PA, USA, has the kind of serenity often only found in the lush, green countryside. It is this sense of peace that Susquehanna Health hopes to convey to its cancer patients in a new, renovated space, complete with a healing garden that was suggested by health system employees.The 282-bed Susquehanna Health includes The Williamsport Hospital & Medical Cen-ter, Divine Providence Hospital, and Muncy Valley Hospital. It is ranked as one of the nation’s most wired hospitals by Hospitals & Health Networks, and, in 2006, launched a major initiative to renovate its campus facilities, among them the Susquehanna Cancer Center, which is located at Divine Providence Hospital.

Patient-Centered, Physician-Focused

As part of the project, Susquehanna Health hired Granary Associates, Philadelphia, PA, an architectural firm that specializes in health facility design. “The architects’

experience with healthcare facilities was important to us, but even with that we felt it would be best to get outside input re-garding workflow,” says Karen Armstrong, Senior Vice President and Chief Informa-tion Officer (CIO), Susquehanna Health. “We wanted the facility to be patient-centered and physician-focused.”Susquehanna Health has long been a strategic business partner with Siemens Medical Solutions and was, in fact, the first worldwide beta site for the Siemens information technoligy solution Soarian® Financials. Through that relationship, Armstrong and her colleagues were aware of the company‘s Global Solutions Divi-sion’s abilities in process-based facility design. “If you have the right team with the right clinical background and the right credentials to talk with physicians and workers at all levels, you can observe and make good solid workflow recommenda-tions,” continues Armstrong. “We believed the Siemens consultants could really take the project to the next level.”Collin Beers, Senior Vice President at Gra-nary Associates, agrees that the Siemens consultants brought value to the project.

Stepping Outside the Bounds

Thanks to Siemens comprehensive data analysis, Karen Armstrong, CIO of Susquehanna Health, and her team were able to project future volume and treatment types for their Cancer Center.

Facility Planning


tivity and efficiency are important elements in the design, we also needed to weigh that against what was best for the patient.”

Experienced in Workfl ow Design

In fact, key adjacencies were important elements of the consultants’ recommen-dations. By relocating the lab to medical oncology and positioning the phlebotomy station next to the lab, patient wait times are expected to be reduced by 60 minutes. The Siemens consultants also recommend-ed positioning the pharmacy between medical oncology and the chemotherapy infusion area to reduce the distance nurs-es and pharmacists travel to administer medications. And, to further enhance the patient experience, additional consult rooms were recommended so palliative care, pain management, home care and hospice, dietary, and physical therapy caregivers could come to the oncology patient rather than making the patient go to them.“ It’s important that the architects and consultants are on the same page when it comes to space considerations. Once we were aware that Siemens was involved in the project, we met with the consultants so we could work together on concept plan development,” says Beers. “The consultants’ feedback was really beneficial. Based on their data, they would suggest certain changes and we would work with them to determine what was architecturally feasible.”

Planning for Future Volume

To ensure that physician, nurse, and other staff workflows were considered in the design, Siemens consultants interviewed key stakeholders, observed current opera-tions, reviewed proposed drawings and technology plans, and gathered available operational data on the existing Cancer Center. “One of the key elements they brought to the table was recommendations on the future incidence of cancer in our area so we could plan for potential future volume,” says Armstrong. “They looked at patient demographics and the types of

“If our client is using a fairly contemporary approach to space planning, we let it stand. But the Siemens consultants were able to ask tougher questions about why certain workflow processes were the way they were,” he says. “Because they were brought in to analyze efficiency, the dia-logue took on a whole different angle.”

Improved Effi ciency and Outlook

The medical oncology and radiation oncology service areas currently reside in an 11,000-square-foot space in the base-ment of Divine Providence Hospital. In this location, the services are restricted from growth by other spaces – another service line above it and the earth itself around the basement. When the service line above the Cancer Center relocated, the option to renovate this space and expand the Cancer Center became more realistic.Granary Associates worked with some of the Cancer Center’s key stakeholders to review potential options and balance the Center’s clinical needs with its budgetary requirements. The new proposed space – at 34,000 square feet – had the potential to offer significant improvements: Medical oncology could be moved to the upper floor, allowing the infusion chairs to be positioned near a large window overlook-ing a healing garden. “One wall of the existing building will be primarily glass, which will offer us considerably more light and contribute to an overall fresh look and feel,” says Armstrong.After reviewing the initial concepts for the two-floor center, Siemens consultants helped develop a conceptual floor plan that was more conducive to the patient experience and the physicians’ and staff’s workflows. Patient flows were created for each patient type – both in medical and radiation oncology, from initial consult visit, new patient visit, follow-up doctor visit, chemotherapy infusion, to radiation therapy treatment. “Oftentimes, when physicians and nurses make suggestions for facility design, they do it with the convenience of the staff in mind,” says Armstrong, “and while the staff’s produc-

Challenge:• Expand and redesign Cancer

Center with regard to workflow requirements and patient needs

Solution:• Create patient flows for each

patient type and visit – both in medical and radiation oncology

• Relocate the lab to medical oncology, position the phlebo-tomy station next to the lab

• Position the pharmacy between medical oncology and the chemotherapy infusion area

• Establish additional consult rooms for palliative care, pain management, home care and hospice, dietary, and physical therapy

• Project the future incidence of cancer in the area to plan for potential future volume

Result:• Patient wait times for lab

results are expected to be reduced by 60 minutes

• Reduced distance nurses and pharmacists cover to administer medications

• Caregivers can come to the oncology patient rather than making the patient go to them

• Projection resulted in more in-fusion rooms, less exam rooms, plus shell space for easier and cost-efficient installation of a future linear accelerator

Summary

Facility Planning


Facility Planning


Further Informationwww.siemens.com/medical-consulting

Susquehanna Health not only engaged the Global Solutions team of Siemens Medical Solutions for the process-based facility design of its Cancer Center, but also asked Siemens consultants to participate in the planning for a brand-new outpatient imaging center. The Siemens consultants examined Susquehanna’s imag-ing technology deployment based on demographics, services, resources, utilization, and efficient patient processes. “In partic-ular, we wanted their expertise to determine what modalities should remain in the hospital and which ones we should take out or duplicate at the imaging center,” says CIO Karen Armstrong.The Global Solutions team recommended, for example, that Susquehanna locate its high-volume procedures near the waiting room to reduce the distance covered by patients and congestion in the corridors. Additional recommendations included relocat-ing some existing technology in The Williamsport Hospital to the ambulatory imaging center to reduce overall capital costs. Capital dollars saved could then be used to invest in new imag-ing technology.“They confirmed some facts about the productivity of our com-puted tomography [CT] and ultrasound staffs, which quantified this information for us in a way that had never been done before,” says Armstrong. “And beyond the technology recom-

Optimizing Assets and Identifying Opportunities to Increase Revenue

mendations, they also suggested hiring a CT aide. Rather than using expensive technicians, we could use this person to do the routine stocking, help transport patients and assist in getting them ready, run errands, and handle some basic paperwork.”Other significant benefits could be realized through changes to Susquehanna’s existing patient flow processes and staffing procedures. By creating an intravenous (IV) preparation area, patients receiving IV contrast can have their IV started outside the CT scan room, which eliminates approximately five minutes for every contrast exam performed and equates to the potential for an additional 2,100 appointments per year. An assessment of the existing staff resources also found that the scheduled hours of operation in CT and ultrasound could be expanded. By scheduling full-time staff on evenings and week-ends (which were previously covered by on-call staff), the health system could decrease its annual staffing costs by about $40,000 in the first year. In addition, adding weekend appointments significantly reduces the radiology department’s scheduling backlog.All of these recommendations are being taken into consideration as Susquehanna Health moves to the groundbreaking phase of the project, which is expected to occur by late 2007.

cancer that are likely to occur in our area, and were able to project the size of the facility that would be necessary and the number of chemotherapy infusion areas and exam rooms that we would need in the future.”Compared to the original plans, this poten-tial volume evaluation resulted in an in-crease in the number of infusion rooms and chairs needed from 12 to 18, with 8 of them as private rooms. The number of exam rooms decreased from 19 to 14 rooms. Furthermore, based on the high utilization of their current equipment, the consultants recommended building shell space for a future linear accelerator. Plan-ning and building for future technology saves construction costs and limits the disruptions to daily operations when the equipment is installed in the future.“It was the first time we had worked with workflow-efficiency oriented consultants,” says Beers. “We’ve worked with other stra-tegic partners, usually business-oriented consultants who, after they have com-

pleted a business model or justified a need, tend to not go any further with the project. But the Siemens consultants were there all the way through. And at the end, we knew we had a plan that had been challenged. It wasn’t just a recreation of the way Susquehanna had worked before.”“Our experience is limited by what we know to be true here; it doesn’t necessarily help us forecast for the future,” says Armstrong. “That’s where the consultants come in. The Siemens consultants are credible and professional, and have the credentials and experience that go a long way towards not only making our staff feel comfortable, but also getting them to understand the rationale behind the recommendations. We know they will help us achieve good, efficient outcomes.”

An award-winning journalist, Karen Schweizer’s articles on health and medical technology have appeared in numerous business and consumer magazines. She is currently on staff at Siemens Medical Solutions USA, Malvern, PA, as a writer.

“We know the Siemens consul-tants will help us achieve good, effi cient out-comes.”

Karen Armstrong, Senior Vice President, CIO, Susquehanna Health, Williamsport, PA, USA

Facility Planning


Virus Protection


Virus Protection


This is a message that no one would ever want to receive. University Hospital Basel selected Siemens Virus Protection to reduce the risk of receiving such bad news and to permanently protect its medical systems against viruses, worms, and trojan horses. Now, physicians can concentrate on the hospital‘s patient care and effi cient therapy for complex cardiac, vascular, and metabolic diseases.

By Christian Bernhart

Early in the morning just before seven, the first outpatients arrive at the Univer-sity Hospital Basel, Switzerland, for radio-logical examinations. People who work during the day appreciate the early morn-ing and after-hour appointments. Just past the main entrance at the address of Peters-graben 4 in Basel, they take the escalator downstairs and proceed to the registration at the left, where the clinical staff is already waiting for them. The University Hospital operates 40 clinics and institutes, and is equipped with 680 patient beds. The entire lower floor is devoted to radiology, a unit that is furnished with state-of-the-art imaging systems.

350 Patients per Day

The radiological technician (RT) has al-ready booted up the first magnetic reso-nance imaging (MRI) and computed tomography (CT) workstations. The day’s schedule for the normal flow of radiolo-

gical examinations on some 350 patients was set a day in advance. The patients are identified during registration, sent to the appropriate waiting area, and taken from there to the examination as quickly as possible.

More Security for Larger Capacity

In addition to the 140 outpatients from the hospital’s clinics and referring physi-cians, the RTs bring another 210 inpatients to the radiological examination stations. At 7:45 a.m., the first patient is being examined at the angiography station. Here, cardiologists have two systems to exam-ine arterial vessels. In addition, therapy is performed on cardiac, renal, and brain blood vessels. In the two standard radiog-raphy rooms, the first patient examina-tions began at 7:00 a.m. By midday, up to 120 radiographic diagnoses are already available.

Virus Protection to Safeguard Both Patient Care and Systems

Virus Protection


The Siemens imaging systems in radiology deliver 10,000 fully digitized patient images per day at a volume of 18 giga-bytes, which are processed at five work-stations and then forwarded. In addition to system quality, operating reliability is the primary objective, explains Professor Wolfgang Steinbrich, MD, Director of the Institute for Diagnostic Radiology. “Today, our capacity is designed such that the systems always have to function.” Take CT, for example: To manage today’s num-ber of examinations six years ago, the hospital would have had to purchase four systems. But thanks to fast technology and increased patient throughput, two CT systems are currently sufficient. “If one system were down, however, the disaster would be that much greater,” reflects Stein-brich. He starts to talk about Siemens Virus Protection that was installed on all 27 Siemens systems. When he learned of the special Siemens Virus Protection for medical systems, he did not delay in pur-chasing it. He reasoned that his computer, connected to the Internet and the hospi-tal’s administrative network, always oper-ates with a virus protection program as well.

Security without Interruption

Highly complex medical systems need this type of protection to an even greater

extent, especially given the fact that the technology is far more complex than that in a PC, as Steinbrich quickly determined. For the radiological systems used in exami-nations and therapy, it is not just a ques-tion of protection against viruses, worms, and trojan horses. Much more is required to protect patients against safety relevant events possibly resulting from attacks, and to ensure the systems run without inter-ruption.This is enabled on the one hand by well-trained experts. A full-time RT is responsi-ble for the smooth flow of examinations from 7:00 a.m. to 7:00 p.m. Inpatients fill the time between outpatient appoint-ments, emergency cases are examined in two radiography rooms on the ground floor next to the emergency room, and polytraumatic cases go for diagnosis and initial surgical intervention to the multi-functional image-controlled intervention room (MII). The room is equipped with CT and MRI systems, and is operational around the clock.Siemens Virus Protection ensures long-term, reliable operation discretely in the background, barely noticed by the trained experts. Early in the morning, when the systems are reset or booted up after being off for the night, Virus Protection reports in on a regular basis: “A new virus pattern file is available for your virus scanner. This will allow the identification of new viruses

on your computer. We recommend that you perform the installation immediately.” Clicking ’install’ is all that is needed to equip the systems with the latest virus patterns.

Special Scanner

Siemens Virus Protection is certainly not a standard product. Virus protection technology for medical imaging systems is far more complex than that for con-ventional PCs. For this reason, Siemens relies on the know-how of the well-known company Trend Micro, Inc. “It is important to understand,” explains Andreas Lang, who is responsible for MRI systems at Siemens Switzerland, “that Siemens does not simply use the standard scanner as it can be purchased from Trend Micro by private users without testing it on a pro-duct-specific basis. Additionally, Siemens development departments cooperate closely with Trend Micro to avoid any unintended adverse effect on medical system security.“For example, on interventional systems, the virus scanner is specifically configured to switch off briefly during critical phases of diagnosis and therapy, and then switch back on. As a result, Siemens avoids a critical behavior that may happen with im-properly configured commercial scanners. As part of their continuous monitoring

“We are glad to have found a competent and reliable partner with Siemens to implement this innovative and proactive solution.”

Franz Buffon, Director of IT, University Hospital Basel, Switzerland

Virus Protection


“With its Virus Protection, Siemens has set a new standard.”

Christian Kluth, Director of Medical and Operational Technology, University Hospital Basel, Switzerland

Virus Protection


Challenge:• Danger of a virus, trojan horse,

or worm infection in a hospital IT network

• System shutdown during com-plicated, computer-supported treatments

• Security of image and patient data jeopardized

Solution:• Virus scanner installation of

the thoroughly tested virus scan-ner Trend Micro™ OfficeScan™ to continuously monitor the system for malicious attacks

• Ongoing automatic remote virus scanner updates of the latest validated virus patterns and scan engine

• Fast virus elimination in the event of an infection through continuous Event Monitoring of the system, the customer enjoys preferred and rapid expert assistance while getting the system back online again

• Security hotline: Siemens UPTIME Service Center

• Regular proactive monitoring, careful assessment and vali-dation on a product-specific basis of hotfixes released by Microsoft

Result:• Secure workflows throughout

the Radiology Department• Protected patient and image

data• Immediate help for problems

that occur on short notice

Summary

of information, these units automatically react to a virus by immediately stopping the data flow.

Tested for Operational Safety and Reliability

The security provided by Siemens Virus Protection extends beyond the specialized scanner. The patterns that Trend Micro sends to customers on a regular basis to detect new viruses and worms are not simply taken for the medical equipment. First, the Siemens Virus Competence Center tests whether the patterns could have a negative impact on the operational safety of the systems. Once thorough testing is completed, Siemens transfers the patterns directly to the users’ systems. Now they are ready to detect new viruses and worms. But what makes the ‘real pro-tection?’ The workstations used by phy-sicians, cardiologists, and RTs to process images and generate diagnostic reports run with the Windows® operating system. As such, they have to rely on updates from Microsoft®. That is why Siemens Virus Protection includes the provision of tested Microsoft hotfixes that are relevant to the software used in their medical systems.

Automatic Feedback

Siemens Virus Protection at University Hospital Basel is not only active during the installation of new virus patterns. All sys-tems are linked to Siemens online via an encrypted virtual private network (VPN). When a critical situation arises, Siemens is often the first to know what the problem is. Rolf Aepli, who is responsible for angi-ography systems at Siemens Switzerland, explains it this way: “Technically, our systems are equipped to report directly as soon as they have a stomach ache.” Another advantage: The tested virus pat-terns reach the individual systems directly via the specific Internet Protocol (IP), sav-ing time.The Virus Protection processes are reviewed in a protocol every month by Christian Kluth, Head of Medical and Operational Technology of the University Hospital Basel. Detection of a virus in a system is recorded as well. “To date, we have for-tunately not received any messages indi-

cating a virus,” states Kluth. But how high does he classify the risk of a medical sys-tem infection, given the fact that the in-formation flow of the systems connected to the radiology information system (RIS) network is separate from the administra-tive network of the University Hospital Basel?Kluth notes a recent example just before the installation of Siemens Virus Protec-tion, where the speed of data traffic for an imaging system dropped significantly. The hospital’s internal IT department determined that this system had released a virus that flooded the network with use-less data. The experience showed Kluth that one can never assume a clean net-work. “Such an assumption would be as incorrect as someone going on the Inter-net and demanding that it take steps to remain free of viruses.” For this reason, Kluth believes that device manufacturers should not assume that operators, and specifically university hospitals, can guar-antee a clean network. “With its Virus Protection, Siemens has set a new stan-dard,” says Kluth with certainty.

Network Risks and Memory Sticks

In the foreseeable future, RIS data at University Hospital Basel will be managed via a picture archiving and communication system (PACS). This will enable physicians to simultaneously compare images from the RIS with patient data from the hospital information system (HIS) when making evaluations. It will also increase the inter-faces between the individual networks, and therefore the risks. Other possible sources of infection include data transfers from memory sticks or connected lap-tops. For Franz Buffon, the Head of IT at the University Hospital, this represents a particular challenge to the university because researchers and professors world-wide visiting for conventions and sympo-sia can enter data into the hospital net-work via a computer or laptop. Scanners on the administrative hospital network eliminate some 11,000 viruses daily. Recently, the hospital IT department decided that PCs or laptops would not be allowed to run on the network unless previously validated. In addition, the user


Christian Bernhart works as a scientific journal-ist in the areas of medicine and technology. He is also editor for University Hospital Bern‘s visceral medicine topics, and writes for well-known daily and weekly newspapers, as well as German mag-azines like Bild der Wissenschaft.

has to be authenticated via a user name, password, and perhaps soon via finger-print, before logging on.

Trust as a Prerequisite

The RTs in Radiology on the lower floor of the hospital rarely look at such consider-ations during their busy day. By now, it is midday. The radiological technician res-ponsible for scheduling takes a short break, although the work within the department continues. Looking at an on-screen moni-toring system, she sees that the depart-ment is on schedule. Thirty patients have been diagnosed via MRI, another 33

via CT. Sixteen patients have undergone therapy in angiography, and 117 patients have been X-rayed. Fortunately, there has been no interruption in the work using the reliable systems. Should a virus infec-tion occur, it is the task of the Siemens experts to make the system operational again. The direct online connection to Siemens meets the requirement of being able to intervene immediately and cor-rect the situation. This direct connection between the University Hospital and Siemens requires trust and long-term cooperation. As Franz Buffon explains, “We are glad to have found a competent and reliable partner with Siemens to

The Siemens imaging systems in radiology deliver 10,000 fully digi-tized patient images per day. According to the Head of Radiology at the Univer-sity Hospital Basel, Profes-sor Wolfgang Steinbrich, it would be “a disaster if one system were down.”

implement this innovative and proactive solution.“

Further Information

www.siemens.com/virus-protection

C-arm in Gastroenterology


Dr. Maier, you tested the new C-arm, ARCADIS™ Avantic, in your gastroen-terological department. What can you tell us about the results obtained?MAIER: I want the system to be shown at all exhibitions relevant to our specialty. The quality is so convincing that even a short ‘dry run,’ as you can show at events like these, could make anyone take notice – anyone who knows about the requirements that a C-arm in gastro-enterology has to meet.

What characteristics of the new system impressed you most?MAIER: First of all, the performance-oriented image intensifier. Combined with

The multitalented ARCADIS Avantic examines more than just hearts and kidneys. The mobile 33-centi-meter image intensifi er opens up innovative oppor-tunities for gastroenterologists. Journalist Martina Lenzen-Schulte interviewed Matthias Maier, MD, Head of the Department for Internal Medicine at the Knappschaft Hospital Püttlingen, Germany, to discuss the new C-arm.

Better Abdominal Images

the generous image segment available for review, it provides excellent image impressions, not only qualitatively but also with respect to dimensions. This is of spe-cial advantage in endoscopic retrograde cholangiopancreatography (ERCP).

Can you explain this in greater detail?MAIER: ERCP is one of the most frequent interventional procedures in gastroenter-ology that requires X-ray control. Using the endoscope, the entrance of the bile duct and pancreatic duct is reached via the duodenum. The digestive enzymes from the liver, gallbladder and pancreas empty into this opening. It is possible to visualize these pathways by using an X-ray

C-arm in Gastroenterology


“Exact imaging is extremely helpful in determining the smallest irregularities. I consider the ARCADIS Avantic to be an extremely precise system.”

Matthias Maier, MD, Head of Internal Medicine, Knappschaftskrankenhaus Püttlingen, Germany

contrast medium. Unfortunately, they are partly located apart from each other. The large field of view of ARCADIS Avantic, however, allows me to simultaneously view all anatomical structures of interest for the actual intervention.

When and why is that important?MAIER: We are frequently dealing with patients where bile or other liquids have collected because of obstructions in the duct systems – for example, through gall-stones or tumors. When the interventional gastroenterologist applies drainages, and monitors them via contrast medium, it is very helpful to see everything at a glance without having to search around with the

image intensifier. In addition, drainages are often applied percutaneously, that is, through the skin, to the liver or bile ducts [PTCD – percutaneous transhepatic bile duct drainage]. In this case, the structures to be evaluated are even further apart. It is not possible to see them together in one image by using conventional devices with small image intensifiers.

Actually, you are now addressing size. Could you also talk about advantages that arise from the improved image quality obtained?MAIER: We are talking about more than one advantage here. We tend to deal fre-quently with adipose patients. This applies

in particular to patients who suffer from gallstones and frequently makes evalua-tions under fluoroscopy rather difficult – unless you have a system that has that much power. Even very thin wires of the instruments which were previously diffi-cult to detect can be seen with ARCADIS Avantic.Additionally, these wires are getting to be thinner and thinner; years ago they measured approximately 0.09 centimeters. Today, we are using a fraction of this with as little as 0.05 centimeters. For this reason, we are running into problems with average-sized patients as well if the resolution of the image intensifier is not high enough.

This means that you have improved documentation because the images show the details.MAIER: Correct. And it is not just advan-tageous for this indication. I simply see more with ARCADIS Avantic, especially when I have to evaluate the disease pattern of sclerosing cholangitis.

What do you mean and why is it so important with this particular disease?MAIER: The narrowing of the biliary tract caused by scarred connective tissue may occur with chronically inflamed intestinal disease and has to be diagnostically sepa-rated from other diseases and blockages of the biliary tract. Exact imaging is extremely

helpful in determining if the walls are smooth or in seeing the smallest irregu-larities that have to be considered. I con-sider ARCADIS Avantic to be an extremely precise system.

Does this apply to malignant changes as well?MAIER: Most certainly. To eliminate small tumors, sometimes the image quality of conventional systems does not suffice. Again, it has to be emphasized that good documentation of these types of reports is of major importance. This applies also to cases where we place stents into the biliary tract as well as the esophagus to overcome constrictions and keep them

open. Such constrictions may have been caused, for example, by malignant growths.I expect that this procedure will become more frequent due to consistently improv-ing chemotherapies. Survival rates are steadily increasing. As a result, stents have to be replaced more often, or constrictions have to be expanded through bougienage to provide patients with a better quality of life. In addition, the location of stents has to be checked over and over again when the patient is experiencing new dis-orders.

How did you experience the handling of ARCADIS Avantic?


The transportable ARCADIS Avantic allows for flexible application in the hospital.

Challenge:• View all anatomical structures of

interest during an gastroenterolog-ical intervention simultaneously

• Adipose patients and thinner wires make detection more difficult

Solution:• 33-centimeter image intensifier• Improved spatial resolution

Result:• Optimized navigation with a per-

formance-oriented image intensifier and generous image segment

• Improved documentation with an extremely precise system

• Easy handling of the operation panel

• Flexible application in the hospital

Summary

Martina Lenzen-Schulte, MD, is a physician, author, and medical journalist. She is a frequent contributor to medical magazines and the scien-tific pages of German-speaking public media.

MAIER: It’s a highly sophisticated device and not in the least cumbersome for such a large system. You don’t need physical strength to operate it. In addition – and we consider this to be highly advanta-geous – you can swivel the control panel in any direction. If a coworker is located right next to the patient, he or she can turn the operating panel in his or her direction. I also consider it a huge advan-tage when I work alone.

Can you explain this in greater detail?MAIER: When I establish a drainage to relieve a cyst filled with fluid in the pan-creas, for example, I like to set the images myself as well. The large image segment of ARCADIS Avantic allows me to see everything of importance without having to shift anything. I just need to have my colleague superimpose details, also with consideration of X-ray protection, which is a rather simple procedure. I can leave my hands on the endoscope. This reduces the chance of accidentally shifting guide wires.

We have already talked about the enthusiasm of angiologists and cardiac

surgeons for the multifunctionality of the new image intensifier [Medical Solutions, June 2007]. Is this feature also of importance to you in your role as head and, thus, economic decision-maker, of the department?MAIER: I’d put my name to this. This is a mobile device and can be used anywhere. In a hospital that does not have several angiography suites, it’s highly advanta-geous to have a backup. When the system breaks down, it ensures that emergency angiography procedures can still be performed. I consider this an important deliberation with respect to economic planning in a hospital that wants to offer many interventions.

Is there room for improvement?MAIER: I hope that many people use this system. I’d like to repeat what I said in the beginning: The system should be intro-duced more often to potential users at exhibitions.

Further Information

www.siemens.com/Arcadis-Avantic

Further Reading

Siemens takes mobile detector technology a step further, enhancing flexibility and improving workflow by going wireless. The wireless detector of the new Ysio wi-D* means easy detector handling and posi-tioning without constraints of cable length and furniture placement in the room. As a member of Siemens universal digital radiography solutions, Ysio wi-D provides the best of both worlds with an integrated detector in the wall stand and the wireless mobile detector (wi-D) in the table. The table detector can be removed for out-of-bucky work. The design delivers flexibility in detector utilization to cover nearly all radio-graphic projections.Aside from the mobility benefits of going wireless, the ingenuity of the design includes a battery pack and electronics for wireless local area network (LAN) transmission. The Ysio wi-D detector weighs less than five kilograms. Its robust design is optimal for daily handling in the clinical environment, and it is sufficiently watertight for safety and hygiene. For workflow enhancement, Ysio wi-D offers fully automated system positioning linked to organ programs for fast workflow and a touchscreen user interface for convenient imaging parameters modifi-cation. With the latest generation of detectors, Ysio wi-D will be primed for future technological applications.

Not Just the Regular Mobile Detector

Ysio wi-D is the latest digital radiography solution that combines two different detector designs for optimal workflow enhancement.

www.siemens.com/AXIOM-RSNA-2007-wi-D

In today’s surgical environment, the need for mini-mally invasive procedures and cutting-edge technol-ogy becomes ever more important. Siemens Medical Solutions and the Center for Molecular Imaging Research (CMIR) at Massachusetts General Hospital (MGH) in Boston, USA, have been working together for four years as part of a strategic alliance to further the field of molecular imaging and test cutting-edge imaging applications in laboratory models and clini-cal studies.Just recently, a new generation of contrast agents using optical fluorescence-labeling technology was developed that could change the way in which surgeons detect cell abnormalities such as cancer. Fluorescence-guided surgery can help determine the procedure needed to wither, repair or remove affected tissue.As part of its collaboration, Siemens has also inves-ted in VisEn Medical, Inc., a company that is devel-oping and commercializing imaging technologies that translate the recent breakthroughs in genomics and proteomics into real-time, in vivo molecular mapping of disease states. The imaging technology that has resulted out of this collaboration should help revolutionize surgical intervention.

Fluorescence-guided Surgery

Completely new imaging possibilities have become available with Large Volume syngo® DynaCT*. With Artis™ zeego*, the new multiaxis system for interventional imaging, it is now possible to acquire a larger 3D volume with a flat detector than ever before – an industry first. A diameter of 47 centimeters and a

Large Volume syngo DynaCT

Large Volume syngo DynaCT could enhance imaging possibilities in today‘s interventional radiology.

height of 18.7 centimeters can be covered. This extended field of view is especially important to treat liver tumors via chemo-embolization, as it can visualize the whole liver. Better coverage of the abdomen plays an important role when imaging already enlarged livers or obese patients. Needle work, biopsies, and radiofrequency ablations can be easily completed with full orien-tation due to the excellent large volume soft-tissue imaging.Even in portrait mode, large volumes can be acquired with syngo DynaCT. In this mode, it is possible to acquire volumes with a 25-centimeter height and a 35-centimeter diameter. This extend-ed field of view allows coverage of the whole thoracic spine. It is very helpful when performing spinal procedures such as verte-broplasties, kyphoplasties, lumbar punctures, and myelographies. The portrait mode is also a valuable application for carotid stent-ing. The results of the stenting procedure can be verified imme-diately after placing the stent. The cerebral vessels as well as the carotid artery can be seen in one image.

www.siemens.com/Solutions-RSNA-2007-Fluorescence

www.siemens.com/AXIOM-RSNA-2007-DynaCT

* The information about this product is preliminary. The product is under development and not commercially available in the USA, and its future availability cannot be ensured.

* The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the USA.


Where’s Parker’s X ray?

Where’s Parker, anyway?

Answers for life.

Our health care IT solutions deliver information when and where it’s needed most. For higher quality patient care at reduced costs.

Siemens solutions in health care IT are helping to connect clinical and administrative information throughout the health care enterprise, giving clinicians, patients and payers the information they need, when they need it, where they need it. This enables informed decisions, and helps deliver more efficient clinical and administrative workflows. Ultimately, innovative health care IT keeps a hospital’s workflow flowing.www.siemens.com/answersforlife

Where’s Parker’s lab report?

CC-Z1046-1-7600

Browsing through this issue of Medical Solutions, you may have noticed some changes in content, structure, and focus. These changes were implemented by the editorial team at Medical Solutions in an attempt to better address your – our readers’ – needs.Which healthcare topics would you be most interested in? Based on various sub-scriber and customer surveys and latest feedback, one-on-one interviews with several readers, a thorough analysis of what leaders in the healthcare industry read – and what Siemens has to offer in that context – we have reshaped the sub-jects of the magazine. Topics we would like to cover include workflow, knowledge-driven medicine and healthcare IT, molec-ular medicine and in vitro diagnostics. Other features will be trends in health-care, healthcare policy, architecture and planning of healthcare facilities, as well as personnel management and human

resources. All articles will focus on customer experiences and benefits, and feature hard facts and figures.Other changes we have implemented may seem minor at first glance, but we are sure they will make reading Medical Solutions more convenient for you. These include management summaries for

Feedback

Trade Fairs & Congresses

a quick overview, Internet links and other sources for further reading, as well as an overview of topics covered in other Siemens Medical Solutions customer magazines.We hope you enjoy reading the new Medical Solutions – and we do encourage your feedback on our concept and articles as well as your topic suggestions. In fact, this section, ’Feedback to the Editor’, is also new. Here, we will publish your feed-back and, in so doing, allow your fellow readers to partake in your experiences and reactions to our topics. We are look-ing forward to hearing from you!

Sincerely,

Doris PischitzChief Editor

Dear Reader,

Feedback to the editor should be addressed to: by mail: Siemens AG, Medical Solutions CC CB1 Doris Pischitz Chief Editor Medical Solutions 91050 Erlangen Germanyby e-mail: editor.medicalsolutions.med@ siemens.comby fax: +49 9131 84-4411

Please include postal address, e-mail address, and phone number. Siemens reserves the right to edit readers’ comments for clarity, length, or compliance with legal/regulatory requirements.

Title Location Short Description Date Contact

Moscow Moscow, Russia International Exhibition Dec. 5 – 9, 2007 www.zdravo-expo.ru/enHealthcare of Health Care, Medical Engineering and Pharmaceutics

EuroEcho Lisbon, Portugal Annual Conference of the European Dec. 5 – 8, 2007 www.euroecho.org Society of Echocardiography

Arab Health Dubai, United International Healthcare Jan. 28 – 31, 2008 www.arabhealthonline.com 2008 Arab Emirates Exhibition and Congress

HIMSS 2008 Orlando, FL, USA Annual Conference and Exhibition Feb. 24 – 28, 2008 www.himssconference.org of the Healthcare Information and Management Systems Society

ECR 2008 Vienna, Austria Annual Meeting of the European Mar. 7 – 11, 2008 www.ecr.org Society of Radiology

ACC 2008 Chicago, IL, USA Annual Scientific Session of the Mar. 29 – www.acc.org American College of Cardiology Apr. 1, 2008

JRS 2008 Yokohama, Japan Annual Meeting of the Japan Apr. 4 – 6, 2008 www.j-rc.org Radiological Society

ITeG Berlin, Germany Information Technology in Apr. 8 – 10, 2008 www.iteg.de Healthcare

World Health Washington, DC, Annual Congress of Chief and Apr. 21 – 23, 2008 www.worldcongress.com Care Congress USA Senior Executives from all Sectors of Healthcare

Service


Imprint


© 2007 by Siemens AG, Berlin and Munich,All Rights Reserved

Publisher:Siemens AGMedical SolutionsHenkestrasse 127, D-91052 Erlangen, Germany

Responsible for Contents: Dr. Stephan Feldhaus

Director of Customer Communications: Silke Schumann

Chief Editor: Doris Pischitz

Editorial Team: Gabriela Castelo, Sonja Fischer, Timo Schickler, Sibylle Schikora, Katja Stöcker, Abigail Weldon

Editorial Assistance: evolo marketing gmbh

Production: Norbert Moser

All at: Henkestrasse 127, D-91052 Erlangen, GermanyPhone: +49-9131-84-7529, Fax: +49-9131-84-4411email: [email protected]

Design and Editorial Consulting:independent Medien-Design, München, Germany

in cooperation with Primafila AG, Zürich, Switzerland

Art Direction: Horst Moser

Layout: Lucie Schmid

Editorial Coordination: Christa Löberbauer

All at: Widenmayerstrasse 16, D-80538 München, Germany

PrePress: MEDia_asset_poolWaldstrasse 18, D-91054 Erlangen, Germany

Printer: Farbendruck Hofmann, Gewerbestrasse 5, D-90579 Langenzenn, Germany

Photo Credits:Cover: Andreas H. BitesnichCover Story: Andreas H. Bitesnich et al.Breast Cancer: Imke Lass, Steffen Thalemann, et al.Electronic Health Record: Jürgen HinterleithnerMarket Niches in MRI: Primin RösliRemote Solutions: Marion Stephan, Jörgen HildebrandtDigitized Hospital: Lars HinsenhofenImage Management: Fabrizio ConstantiniMRI in Oncology: Primin RösliTherapy Control: Marion Stephan, Imke LassRadiology Workflow: Jez CoulsonFacility Planning: Barry G. HolmesVirus Protection: Karl-Heinz Hug, Urs FluryC-arm in Gastroenterology: Sven Paulsten

Note in accordance with § 33 Para.1 of the Federal Data Protection Law: Dispatch is made using an address file which is maintained with the aid of an automated data processing system.

We remind our readers that when printed, X-ray films never disclose all the information content of the original. Artifacts in CT, MR, ultrasound and DSA images are recognizable by their typical features and are generally distinguishable from existing pathology. As referenced below, healthcare practitioners are expected to utilize their own learning, training and expertise in evaluating images.

Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data, such as author’s name and title of the contribution as well as date and pages of Medical Solutions, are named. The editors request that two copies be sent to their attention. The consent of the authors and editors is required for the complete reprint of an article.

Manuscripts submitted without prior agreement as well as suggestions, proposals, and information are always welcome; they will be carefully assessed and submitted to the editorial conference for attention.

Medical Solutions on the Internet:www.siemens.com/medical-magazine

DISCLAIMERS: Practice of Medicine: “The information presented in this magazine is for illustration only and is not intended to

be relied upon by the reader for instruction as to the practice of medicine. Any healthcare practitioner reading this information is

reminded that they must use their own learning, training, and expertise in dealing with their individual patients. This material

does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard.“

Contrast Agents: “The drugs and doses mentioned herein are consistent with the approved labeling for uses and/or indications of

the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses

prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the MR/CT

System. The source for the technical data is the corresponding data sheets.”

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Siemens Medical Solutions – Customer Magazines

Our customer magazine family offers the latest information and background for every healthcare fi eld. From the hospital director to the radiological assistant – here, you can quickly fi nd information relevant to your needs.

Medical SolutionsInnovation and trends in healthcare.

The magazine, published three times

a year, is designed especially for

members of the hospital management,

administration personnel, and heads

of medical departments.

AXIOM InnovationsEverything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semi-annual magazine is primar-ily designed for physicians, physicists, researchers, and medical technical personnel.

SOMATOM SessionsEverything from the world of computed tomography. With its innovations, clinical applications, and visions, this semi-nnual magazine is primarily designed for physicians, physicists, researchers, and medical technical personnel.

MAGNETOM FlashEverything from the world of magnetic resonance imaging. The magazine presents case reports, tech-nology, product news, and how-to‘s. It is primarily designed for physicians, physicists, and medical technical personnel.

For current and older issues and to order the magazines, please visit www.siemens.com/medical-magazine

On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this magazine are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases.

Siemens reserves the right to modify the design, packaging, specifications, and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information.

Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

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© 12.2007, Siemens AG Order No. A91CC-00026-M1-7600Printed in GermanyCC 00026 ZS 120737.ISSN 1614-2535

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