RSNA 2021 Journal – Observations from a Remote Attendee

“It is important that we understand the importance of our role in a value-based system and leverage the tools that enhance our ability to provide subspecialized expertise to patients, the medical community and the public at large.”

Mary C. Mahoney, M.D., President, RSNA
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Last week the annual Radiological Society of North America conference and exhibition was held in Chicago. As I highlighted in my previous post, this is the largest medical imaging conference in the world. And although the pandemic has forced some tough decisions to be made by the conference organizers, this year marked a return to in-person attendance – albeit with some significant modifications to the rules.

I decided to follow the conference remotely again this year. And, I must admit that I didn’t miss the trip to Chicago and the endless walking through the exhibit halls of McCormick Place to check out all the vendor offerings. But, since I’ve spent the bulk of my professional career in medical imaging, I’m still interested in the technology, the profession, and the clinical developments in the industry. So, after spending the past week reading all of the press releases, watching the virtual vendor presentations online, and talking with some of my former industry colleagues, I thought I would share some observations on both the educational and technical exhibitions.

General Observations

RSNA 2021 Attendance Sees 55% Drop from 2019 Level – The total in-person registration as of November 29th was 21,300, including 11,173 professionals registered. Final registration totals will be available in early January. That 21,300 figure is down 55% from the overall attendance figure for RSNA 2019, which was 47,011 (with 21,837 professional registrants). That figure had, in turn, represented a 3.3-percent drop from the 48,615 statistics from RSNA 2018, while in 2017, the total attendance had been 48,445. The advance registration for this conference was 26,348 (with professional advance registration at 16,028). The number of vendor companies of all types exhibiting this year has also declined significantly from two years ago. This year, 571 companies exhibited, down 27.63% from the 789 exhibited in 2019. That 789 figure at RSNA 2019 had represented a 13.8-percent jump over the 693 shown in 2018. As reported by on-site attendees, there were between 40 and 50 vendor no-shows where booths sat empty.

The RSNA did an admirable job creating a safe environment for attendees throughout the conference and exhibition. Registrants were required to show proof of vaccination before receiving their conference credentials. On-site registration was said to be very easy, taking only about five minutes, according to some reports. Masks were required at all times – a City of Chicago requirement. RSNA also offered two onsite COVID-19 testing options during RSNA 2021, with results available 60 minutes after testing.

Several colleagues I spoke to who attended in-person said this was the best RSNA they’ve attended. The lower attendance allowed for companies to present to those who were serious about implementing technology sooner than later. You could have a substantive conversation without having someone else crash your demonstration.

Educational Sessions

Addressing inequities in access to medical imaging – Radiologists are well-positioned to develop strategies for mitigating health disparities through the thoughtful application of radiologic technology. This includes utilizing electronic medical records and demographic data to identify individuals at an increased risk of missing screenings or missed follow-up imaging. Targeted outreach can then be offered to avoid these missed opportunities for care. The hope is that the coalition of patient-focused radiologists will collect and disseminate resources and best practices, advocate for and connect with patients and community members, and collaborate on programs and services that empower others to act.

AI in medical imaging – Applications that improve radiologist efficiency was not nearly as likely to attract investment as those that help organizations capture more patients. An AI application that helps bring more patients back for follow-up imaging, for instance, has the potential to add tens of thousands of dollars to an organization’s bottom line. Adoption remains low, however, with only one-third of organizations currently using AI in their practices. AI continues to demonstrate promise as a tool to speed up imaging exam times — up to 70% faster for spine MRI studies — and reduce dose, including 90% less dose needed for gadolinium-based contrast agents. More on AI in the technical exhibits section in a bit. Here’s a great graphic from Dr. Bertalan Mesko and his team at The Medical Futurist Institute showing the major milestones in AI development in healthcare:

Image Credit: Bertalan Mesko, M.D.

Radiomics role in medical imaging – Several sessions discussed the increasing use of radiomics in clinical practice. One session reviewed applying radiomics, and machine learning to FDG-PET/MRI can noninvasively assess nodal status and treatment planning for breast cancer patients. Out of the eight radiomics models the team developed, the one that had radiomics features extracted from dynamic contrast-enhanced images, antibody-drug conjugates, and PET images showed the highest accuracy for predicting lymph node status. Another presentation reviewed a combination of radiologist assessment and a radiomics classifier to significantly improve the accuracy of MRI for predicting treatment response in cases of rectal cancer. Presenter Mitchell Chen, Ph.D., of Imperial College London in the U.K., and colleagues assessed the utility of CT radiomics in a retrospective study involving 292 NSCLC patients diagnosed at their institution over four years. They presented clear evidence supporting the clinical utility of CT-based radiomic analysis in NSCLC.

Technical Exhibition

AI promoted heavily, but buyer beware – Over half of the vendors claimed to have some form of artificial intelligence (AI), including nearly all the major companies. That said, you needed to dig deeper to understand what they meant by AI versus the industry’s shared understanding of AI. While there are standards for AI, there still isn’t a uniform descriptor of what medical imaging AI is other than what is in the mind of some company’s marketing department. Yes, AI can help with improving signal-to-noise ratios and even with adapting hanging protocols, but that is not what most people are looking for when they look at AI. As reported by Michael Cannavo:

“Real AI” was out there, although anyone who says it is a developed marketplace is sadly mistaken. Fewer than a dozen vendors have more than 20 paying customers using their algorithms, even though they might claim to have 200. Alliances are being formed between several AI vendors who have decided to partner up after realizing the movie dialogue cliché, “this town ain’t big enough for two of us,” or in the case of radiology AI, the 200+ of them.

Michael J. Cannavo, Aunt article

Reimbursement is still an issue. New Technology Add-On Payments (NTAP) are a class of reimbursement meant to help pay for new technology that is not included in the diagnosis-related group (DRG) bundled payment. Unless something changes, NTAP payments for AI applications will expire next year. And, radiologists have finally realized that platforms are more important than point solutions for AI. As Mike points out in the quote above, there’s significant consolidation in the industry, and partnerships to create total AI platform solutions will become dominant in the next several years. Here’s a link to a video interview Brian Casey, Editor in Chief of Aunt Minnie, did with Dr. Paul Chang of the University of Chicago on AI in imaging at RSNA 2021.

Informatics – PACS, vendor-neutral archives (VNA), and enterprise imaging systems (EIS) were all displayed on the exhibit floor, with VNAs making a resurgence of sorts. But with a few exceptions, most of the excitement around PACS/EIS primarily involved upgrades for those using their existing products. PACS vendors continued to place a major emphasis on their respective cloud advantages, and there was a widespread consensus that cloud is on every imaging IT roadmap.

Photon-Counting CT is the talk of the exhibition – Siemens Healthineers executives touted the benefits of its photon-counting CT technology, which is finally reaching the market after 15 years of development work. There are currently over 20 scanners in operation in the U.S. and Europe, most at university hospitals, according to company executives. The fact that they were able to keep this under wraps until the RSNA had competitors scrambling to counter the announcement. In a press release, GE reported that researchers at Karolinska Institute in Sweden had begun clinical evaluations of a photon-counting CT scanner based on technology from GE Healthcare. And Canon Medical announced that they launched a project with the National Cancer Center Japan to evaluate a new photon-counting CT scanner. Both press releases were pretty much drowned out by the hoopla surrounding the Siemens product launch. Philips promoted their spectral CT scanner and had no mention of photon-counting.

Here’s a link to a video interview that Brian Casey, Editor in Chief of Aunt Minnie, did with Cynthia McCollough, Ph.D., of the Mayo Clinic about photon-counting CT.

Mobile imaging systems take center stage – I’ve discussed the topic of bringing medical imaging to the patient in a previous post. This year’s technical exhibition reinforced that message with several new product introductions and first-time exhibitors. Hyperfine had a booth at the conference to demonstrate their Swoop portable MRI system. Fifty organizations are currently using Swoop. A partial list of these organizations includes Yale-New Haven Hospital; North Shore University Hospital (part of New Hyde Park, New York-based Northwell Health); University of California Irvine; Massachusetts General Hospital; Danbury, Connecticut–based Nuvance Health; and Ohio State University. Samsung Neurologica introduced updated versions of their portable CT systems: OmniTom Elite and BodyTom 64 (FDA 510k pending). New versions of handheld ultrasound systems were on display at several vendors booths. Redesigned mobile digital x-ray systems with smaller profiles, lighter weight, and longer battery life were also shown. This trend will grow in importance as more patient care is delivered in the home, in retail settings, and other points of care outside of the hospital.

MRI: Hold the cryogens, please – While there were many updated products announced at this year’s RSNA, the big trend is toward reducing the need for cryogen refills on systems. The technology seals helium directly into the magnet, such that scanners do not require helium refills or quench pipes. Philips, GE, and Siemens promoted their versions as part of their press releases. Vendor portfolios continue to expand with configurations at 1.5, 3.0, and 7.0 Tesla field strengths. New introductions of permanent magnet open systems like the Velocity MRI from Fujifilm Healthcare were also demonstrated.

Some concluding thoughts:

The imaging industry made the most of RSNA 2021, and everyone seemed happy to be together again after two long years of working from home. As reported by Jake Fishman in The Imaging Wire, “almost every product message at RSNA focused on productivity and efficiency, often with greater emphasis than clinical effectiveness. The AI Showcase highlighted many trends we’ve been seeing all year, including larger vendors transitioning to AI platform strategies, an increased focus on workflow integration and care coordination, and a greater emphasis on radiologist efficiency.”

My one beef is with the marketing messages from some of the vendors. I know it’s tough to differentiate yourself in a mature market, but some of the messaging left me scratching my head. Some examples:

  • We’re going to “democratize data-driven medicine, together.” What does that mean exactly?
  • Our product is FDA approved. No. The FDA doesn’t approve products; they clear them to be marketed, but that’s it.
  • Companies that use numbering designations for their product portfolio. Really? Is 5500 better than 7500? Is the price different for a 3100 than an 8800? My head hurts….
  • Disney-esque knockoffs especially drive me crazy. You folks know who you are. “People Can Tell When You Imagine.” I’d rather not imagine it but actually do something.
  • I’d worry about a company that touts that their product addresses “clinically significant cancer.” Most patients who receive a cancer diagnosis think their condition is “clinically significant.”
  • The same goes for companies who use the “Patients are at the center of all we do” tagline. Maybe if we really were at the center of all you do you’d give us access to our medical data without requiring us to sign away our first-born child or re-mortgage our homes to get a digital copy. And don’t get me started about fax machines….
  • I can’t even count the number of press releases or online virtual exhibits that used the words paradigms, proliferation, future-proof, future-powered, pressing trends, and my personal favorite, ubiquitous. Perhaps spending $32.99 on the latest edition of Roget’s Thesaurus would be in order here?
  • And finally, companies who still insist on using stock photography showing a physician holding up a film of a CT or MRI scan in their promotional materials. News flash – it’s almost 2022, folks. A Shutterstock subscription doesn’t cost that much. But, if you’re serious, I think I still have a lightbox in my basement that I used to do slide editing. Yours free for the asking.

A couple of weeks ago, I wrote a post on what to expect from the conference. So, how did I do with my prognostications? Most were pretty obvious based on the information available at the time. My wild card guess didn’t get as much notice as I thought. And I was delighted to see that the PACSman Awards were featured again this year on Aunt Looking forward to seeing what happens in 2022.

Books I Loved Reading This Year

“A great book should leave you with many experiences, and slightly exhausted at the end. You live several lives while reading.”

William Styron, Conversations with William Styron
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I’ve always loved reading. As a kid, I couldn’t wait to get my library card. Once I finally had one, I would walk down to the Lincoln Park branch of the Chicago Public Library and load up on as many books as I could check out and still expect to read in the two-week loan period. I always had my nose buried in a book. My reading tastes varied widely, even at a young age. I loved science fiction and read everything I could get my hands on. I devoured Azimov’s Foundation trilogy (and am enjoying the Apple TV+ series now – even though it doesn’t match the novels closely). I loved Robert Heinlein, Ray Bradbury, Orson Scott Card, Ursula Le Guin, and countless others. Those writers jump-started my interest in technology and the future – both topics I’ve been fortunate to explore in-depth throughout my professional career.

As I got older, I started reading more non-fiction books – especially biographies and histories. And space, anything about space exploration is on my reading list. Growing up, I watched every Mercury, Gemini, and Apollo mission on TV. I continued to follow the space program missions – from Skylab, through the Shuttle, the ISS, and all the JPL planetary missions, even today (NASA TV is on my Roku device). So, it probably won’t surprise you that there’s a novel about space in my favorites this year.

Getting the list down to a manageable number was tough. But, after a lot of thought, some novel scoring algorithms (none of which would qualify as scientific), and in no particular order, here are six that I’d recommend as a gift to yourself or another reader in your family.

Project Hail Mary by Andy Weir – I did say I loved science fiction, right? Like most people, I was first introduced to Weir’s writing through The Martian. His latest novel is a wild tale about a high school science teacher who wakes up in a different star system with no memory of how he got there. The rest of the story is all about how he uses science and engineering to save the day. I have both the Kindle and Audible versions, and I love that I can bounce back and forth between the two.

The Code Breaker: Jennifer Doudna, Gene Editing, and the Future of the Human Race by Walter Isaacson – Isaacson is another author that I read religiously. I have his biographies of Steve Jobs and Leonardo da Vinci. So when he released this book, it was a no-brainer for me – especially because I’ve followed and reported on Dr. Doudna’s work. The CRISPR gene-editing system is perhaps the most powerful scientific breakthrough of the last decade. I learned a lot from this comprehensive and accessible book about the discovery. Isaacson does a good job highlighting the most important ethical questions around gene editing.

Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response by Andy Slavitt – I’ve been following Slavitt’s work since his days at CMS during the Obama administration. As CMS administrator, he was able to work across the aisle, though quietly, more than some predecessors. His pragmatic problem-solving (he dislikes the word “technocrat”) approach helped him build good ties with much of the health care industry and many governors, including those in red and purple states. I wanted an honest account of what happened during the pandemic and got it in this book.

Deep Tech: Demystifying the Breakthrough Technologies That Will Revolutionize Everything by Eric Redmond – The world of “deep tech” has launched seven simultaneous global revolutions: artificial intelligence, augmented and virtual reality, blockchain and cryptocurrencies, the Internet of Things, autonomous vehicles, 3D printing, and quantum computing—a perfect storm that will drive the global economy for the next decade. Since each of these technologies has applications to health care, I wanted to get a sense of where they stood today from someone who advises groups like the MIT Media Lab and the World Economic Forum. A fascinating read.

The Digital Reconstruction of Healthcare: Transitioning from Brick and Mortar to Virtual Care by Paul Cerrato and John Halamka – This book is part of a series from HIMSS. Although somewhat expensive for an e-book, it is well worth the investment. Everyone is talking about digital health these days and the transitions of much of patient care from hospitals, clinics, and offices to various virtual settings. This book combines Dr. John Halamka’s lessons learned from years of international consulting with government officials on digital health with senior research analyst Paul Cerrato’s expertise in AI, data analytics, and machine learning. Together, these two experts support the contention that these technologies can help solve many of the seemingly intractable problems facing healthcare providers and patients. If you want to move beyond the hype and learn practical, real-world examples of how digital health works, this is THE book to read.

Troy: The Greek Myths Reimagined (Stephen Fry’s Greek Myths Book 3) – Last, but certainly not least, is this latest book from Stephen Fry. I also have the other two but was especially drawn to this volume because I had to study the Trojan myth in high school. Troy is the story of the epic battle retold by Fry with drama, humor, and vivid emotion. This is another one where I have both the printed and audio versions. And hearing Fry narrate his work is a real treat.

Hopefully, one or more of these recommendations has piqued your curiosity or aligns with your interests. I hope you enjoy reading them as much as I have. If you have favorites of your own, please share them in the comments section below. I’m always looking for another great read.