New service and business models are challenging the traditional role of a hospital – as a place where sick people are taken to get better. Instead, a growing body of evidence suggests that the key mission of future hospitals will be to help people to avoid falling ill, and to manage those that do in fundamentally different ways than at present.  Such processes are principally driven by economic pressures and the promise of new technologies. However, patients are also playing a major role.


Patients more proactive
It has indeed been apparent for some time that patients are far less passive than they were in the past. In Britain, a study by the King’s Fund think-tank found patients wished to be far more involved in healthcare decisions. In addition, the study reported that patient satisfaction depended not just on medical outcomes, but also on being treated with dignity and respect.
Emerging technologies are seen as one way to enhance the patient experience, and several popular apps show how rapidly patients have moved to centre-stage. In the US, Heal, a smartphone app, lets patients search for physicians in a manner similar to Uber’s connecting passengers to drivers. Zocdoc, another tool for finding doctors, has added an artificial intelligence-powered Insurance Checker feature which lets patients select and verify insurance information as they are booking appointments.  An app called Welloh goes beyond doctors to give users information about hospitals, pharmacies, care centres and other facilities. Clinical trials are also opening up to volunteers, thanks to an app called TrialReach, which helps patients find open clinical trials for specific medical conditions.
These new health access paradigms resonate strongly with younger patients.  According to a report from Salesforce, over 70 percent want their physicians to adopt mobile health applications.

Apple integrating health apps
Evidence of the opportunities arising from enhanced patient participation comes from Apple, which plans to bring the current clutter of healthcare apps under one roof. Its new Health Records feature will allow users to see their records of allergies, immunizations, lab results, medications and other conditions in a single window and send notifications when any data is updated.
Big Data
One of the most promising and best known tools in the emerging technology arsenal is computing giant IBM’s Watson, which deploys artificial intelligence (AI) to collect and interpret vast amounts of data from medical literature in order to advise on best treatment options. Scores of other tools provide personalized treatment plans for cancer patients using the genetic background of their tumours, accompanied by analysis from tens of thousands of other, similar cases.
These kinds of innovations count on assimilating and interpreting what has come to be known as Big Data. The sources for this data, whose volume continues to grow by leaps and bounds, are many. They include clinical studies, prescriptions, radiological images and a host of other healthcare information.

The Internet of Things
One new source of data is from the Internet of Things. Connected medical devices such as insulin pumps and pacemakers pick up signals and automatically transmit information to networked computers, which allow physicians (and patients) to perform real-time monitoring.
An array of wearable devices to track vital signs are another fast-growing source of medical data. On an individual basis, this may not amount to much. However, when the data is provided by millions of users, its size becomes staggering, as does its potential for providing insights.

Cloud computing
Such a burgeoning mass of data is being generated asynchronously, processed and stored by different machines on multiple platforms. Making it usable is hardly simple.
One promising answer to such a challenge lies in cloud computing technology, which has dramatically reduced the cost of data storage, as well as the time required to process and transfer the data to multiple users at different locations. For patients needing to visit a lot of specialists, the accessibility of their data from a variety of locations can be indispensable.

The Electronic Health Record
One of cloud computing’s biggest areas of impact may be the electronic health record (EHR), one of whose goals was in fact to address the above challenge – patient data access in real time by different specialists.
The EHR has generally failed to meet expectations (and over-expectations). In both Europe and the US, the EHR’s key technical/operational limitation was that clinical and financial data could not be easily shared and exchanged among providers – as many had assumed or otherwise hoped for. In the US, EHRs have generally also failed to meet levels of reporting that support the ‘meaningful use’ requirements of pay-for-performance programmes.

Cloud computing seems likely to give a new lease of life to the EHR. Server-based EHRs always run the risk of system failure, which would prevent access to critical patient data until the server has been restored. Such a scenario does not concern cloud-based EHRs. In addition, cloud services are encrypted and provide security. Cloud-based EHRs also reduce entry barriers to adoption by transferring responsibility for confidential patient information to specialized vendors.

Design and hospital re-purposing
The impact of such developments are reaching into the very design of a hospital. Christopher Shaw, Chair of a professional organization called Architects for Health and founder of the design firm Medical Architecture, believes there is a growing mismatch between the physical infrastructure of a hospital and the nature of activities expected to be required over the coming decades.
One key question here is the future of hospital buildings – whether to renovate and incrementally redesign structures or start afresh. Indeed, even as popular imagination associates future hospitals with robotic doctors, another equally beguiling scenario consists of individualized medicine, extending to some forms of surgery, carried out at home.

Hub-and-spoke models
The reality may lie in between, at least in the foreseeable future. One of the most likely scenarios might be a hub-and-spoke hospital model. Its inside tier would consist of academic medical centres serving larger populations and focused on acute care. The middle tier would be an intermediate-care hospital, located in smaller cities or larger towns and providing longer-term rehabilitation and nursing support. The outer tier would be comprised of polyclinics for outpatient diagnostics and elective care, referred from primary care physicians.  At the periphery would be the patient’s home, with telemedicine treatment, and possibly some form of tele-surgery assisted by paramedical professionals on the scene. Some of the latter may well be robots.

Telehealth
After many false starts, telehealth technology is now on the edge of take-off – helping allocate care to patients more efficiently, by eliminating the need to visit hospitals, when they do not have a need to access concentrated multi-disciplinary expertise.
Telehealth is also seen as a means to bring patients back more quickly to their homes. Indeed, there is a considerable body of evidence which suggests that the sooner patients begin recovery at home, the more quickly they heal.
Telehealth is not only being pushed by technology but also pulled by economics. In the US, for example, healthcare providers of diabetic patient care have to contend with value-based measures. As a result, they are becoming increasingly dependent on real-time data from remote glucose monitors. Telehealth allows patients to be more engaged, and participate with physicians in ensuring better outcomes, by adhering to insulin or other medications.

Emerging models – examples
The challenge facing the emerging healthcare model lies in the best way to integrate resources, delivery and support mechanisms, and the need to avoid duplication. However, there are encouraging signs from several parts of the world.
In the US, Westchester Medical Center Health Network (WMC Health), is an example of the emerging hub-and-spoke hospital model. The core of the system consists of a 1,500-bed facility headquartered in Valhalla, New York, which is the only facility for complex interventions and procedures. Buttressing this are six (intermediate) hospitals, as well as several polyclinics and medical campuses. The system covers a population of more than 3 million people spread over 15,000 square kilometres.

In Europe, there are several efforts to redefine hospital design. In a variation of hub and spoke, Guy’s Hospital at London has developed its cancer centre as a stack of ‘villages’, one atop another, with each providing a different service (radiotherapy, chemotherapy, etc.).
Certain hospitals have sought to move in the opposite direction, bringing a full range of services to patients in one room or area. In Veldhoven, the Netherlands, a new Woman-Mother-Child Center at Maxima Hospital provides prenatal, delivery, postnatal and breastfeeding support services from one room.

UMC+ in Maastricht, NL
Some of the most radical efforts to address the redefinition of the hospital are being explored in the Netherlands, at Medical University Centre+ (UMC+) in Maastricht.
In late 2009, the departments of Dermatology and Orthopedics at UMC+ started out on separate tracks of what is called ‘design thinking’. Each department independently developed and implemented new care and financing systems, closely adapted to what they saw as the real needs of their patients, and combining specialities, which had been traditionally separated.
The key mission at UMC+ is to avoid pushing strategy down individual departments, which have highly specific patient groups, processes and technologies, and instead build strategy bottom up, involving inputs from across the staffing chain.
Nevertheless, the aim of design thinking is to also generate organizational change. Over time, several other departments began applying the methodologies pioneered by Dermatology and Orthopedics, creating a new hospital healthcare model.
Over time, the UMC+ model is transforming  healthcare focused on rehabilitation, to preventive public health and development. The shift has also changed the role of the Board. Directors no longer set out strategies, but make communication possible between different departments. The Board aims to ensure that different departments do not seek to reinvent the wheel, and instead continuously develop and implement internal best practices.

The challenge of demographics
Nevertheless, many challenges still lie ahead. While Internet- and smartphone-friendly millennials are clearly going to benefit from new hospital care models, the bulk of hospital and healthcare needs for the next decade or two lie in the elderly. According to a Partners HealthCare study in 2016, few seniors obtain information or accomplish healthcare-related tasks online. Only 16 percent of seniors said they used the Internet to obtain health information, while just 7 percent contacted physicians online.

Conventional or B-mode ultrasound has been used as a diagnostic imaging tool for over four decades. Over the last few years, however, ultrasound systems have witnessed a blizzard of developments in their underlying technology. This has catalysed a significant change in the patterns of ultrasound usage vis-a-vis other, older imaging modalities, especially in terms of concerns about the latter – for example, radiation risk in X-rays and computer tomography (CT), and cost for both CT and magnetic resonance imaging (MRI).

Technology drivers
The ultrasound market is largely driven by innovations in underlying technologies and more sophisticated software algorithms, which allow manufacturers to offer smaller, more powerful and complex systems.
Key developments include an acceleration in processing speed and enhancement in the quality of diagnostic images – coupled to advances in contrast-enhanced imaging and precision in the timing of image capture. This has been accompanied by a sharp reduction in noise-to-signal ratios in the final data to optimize spatial, contrast and temporal resolution, including rotatable views for better visualization.
GE’s cSound technology, for example, offers CT level image quality based on advanced algorithms that capture much larger amounts of data than possible previously (by some estimates, about a DVD worth of data per second). The technology also makes pixel-by-pixel selections of the most precise information to display.

Developments in transducers, beam formation
Ultrasound has also made quantum leaps in factors such as transducer sensitivity and beam formation. For example, line-by-line imaging in beamformers has been replaced in some systems by large zone acquisitions, allowing users to view examinations in greyscale and colour Doppler. Meanwhile, retrospective imaging makes it possible to process raw data multiple times, while retention of channel domain data allows for patient-specific imaging.
Because of all the above, clinicians are able to use ultrasound to image blood perfusion and blood flow in vessels with diameters of 2 mm and less, with small vessel beds displayed via Doppler flow false-colour 3-D or greyscale reconstructions. The result is better assessments of organ perfusion, which have traditionally been difficult on ultrasound.

Commodification trends
Take-up of ultrasound has also been recently boosted by a growing commodification trend. Certain categories of ultrasound have become relatively inexpensive, mobile and less demanding of power. Mobility-related innovations include portable hand-held devices, and more recently, the world’s first wireless transducer. Even some low-end machines are now enabled for full bi-directional communication with electronic medical records.
As healthcare reforms and budgetary pressures favour use of cost-effective solutions, this has led to especially sharp growth in the use of low- and mid-range ultrasound systems. It is now commonplace, for example, to see ultrasound systems in a recovery room, next to hospital beds, or equipping NGOs at health outreach projects in developing countries.

For many hospitals, this kind of product/technology mix makes sense, since not all patients require the sophisticated features offered by high end machines, while their smaller, inexpensive counterparts provide solutions for an everyday challenge faced by most hospitals – workflow bottlenecks.

High-end remains motor for new applications
At the other end, the high-end segment is leading innovation not only in ultrasound technologies, but driving the overall medical imaging market, too. Despite their cost, the advanced features of premium systems have moved ultrasound well beyond traditional applications such as ob/gyn to interventional cardiology and internal medicine. Several ER clinicians, for instance, now routinely utilize ultrasound for echocardiograms and abdominal imaging, while radiologists and surgeons use it to guide needle placement or perform bone sonometry.
Some cutting-edge areas – such as matrix transducers – remain ensconced in the premium category. Matrix transducers have direct relevance to two fast-emerging applications, namely volumetric ultrasound and 3-D/4-D applications.

Key developments
Given below is an overview of key recent developments in ultrasound systems.

Mobility and Ergonomics
Ergonomics and mobility are being addressed by vendors in order to differentiate their systems and grow user volumes. Some surveys suggest that over three out of four of ultrasound users experience work-related pain, with a fifth of these suffering a career-ending injury.
New-generation ultrasound systems stand out in terms of design. Most are noiseless to permit sonographers to minimize distraction and focus on the exam, with settings customized and organized depending on clinical preferences.
Some have slanted bodies to prevent users hitting their knees or feet on the machine, with keyboards that can be raised or lowered depending on user height, probes that are shaped to the human palm and rotatable LCD monitors for sharing the display with colleagues. Other innovations include the possibility of use in both sitting and standing positions, with memory features to accommodate different users.
Some recent ultrasound machines have tablet-sized touchscreen-based interfaces, which significantly reduces the reach and steps (in some cases by 15-20%) in order to start and complete an exam. This enables faster workflow. Touchscreens allow users to tap in order to start functions, pinch and drag to zoom in and out, and swipe to expand the image. Some vendors offer exam presets, with several enhanced functions such as continuous wave Doppler or transducers.

Miniaturization
As discussed below, there is an increase in the use of ultrasound as an alternative to CT and MRI in many point-of-care (PoC) settings. One of the reasons for the trend is mobility as well as increasing miniaturization. Smaller ultrasound machines provide solutions to concerns about cables or wheeling bulky machines around patient rooms, and address tight space demands in key hospital settings such as the operating room. Compact models can be transported by being wheeled or atop a cart.
In some cases, smaller portable machines can also be moved between departments within a hospital or clinic – on a user’s back.

Enhanced quality drives ultrasound to point of care
Ultrasound images today are available with far-higher resolutions than in the early 2000s, when most physicians were used to pictures being fuzzy. One of the key reasons is enhancement in real-time computer processing of images.
Superior image quality has also driven ultrasound to the point-of-care (PoC) setting – both for diagnostic and interventional procedures. PoC ultrasound is now widely available in operating theatres and emergency rooms. Between 2010 and 2013, anesthesiologists are reported to have doubled the use of ultrasound procedures, and ultrasound is also far more common today in certain interventional procedures such as image-guided biopsies and ablations, previously dominated by CT and MRI.

Volumetric ultrasound development
Volumetric ultrasound allows superior characterizing of tissue and the performance of procedures with far greater accuracy.
Ultrasound was previously only able to capture a single imaging plane, but it can currently acquire volumes. This is because transducers which enable the acquisition of real-time volumes of tissue and allow imaging in multiple planes such as the transverse and sagittal have recently become available. For instance, transducers can detect the altered speed of high-frequency sound waves through adipose layers versus other tissue, and make the system aware of increased adipose content.
Though several new-generation transducers remain expensive, in areas where they make a difference, the added price tag is becoming justified. For instance, high-resolution matrix transducers are finding use in interventional cardiology applications such as trans-esophageal echocardiogram (TEE) and 4D imaging.

3-D/4-D imaging
While 2-D continues to be widely used in clinical applications, recent technological advances such as matrix transducers have been enabling factors and triggered interest in 3-D and 4-D ultrasound.
3-D/4-D ultrasound has a more rapid acquisition rate of datasets and subsequent improved image visualization.
4-D imaging consists of the three spatial dimensions as well as the element of time. It projects a cinematographic, motion picture view of an organ or a specific part of an organ, and is emerging as the next generation in advanced imaging. 

In combination with advanced visualization functions, 4-D ultrasound aids complex surgical applications and interventional procedures. Multiplanar reconstructed (MPR) images are now available for review in the same manner as CT and MR scans.
Leading imaging vendors already offer 4-D imaging products – across all modalities, PET/CT, MRI and ultrasound. However, 4-D ultrasound is capturing a great deal of interest in applications where ultrasound has already made a case for itself, due to cost, mobility or radiation concerns.

The close connection between 4-D and ultrasound dates back to cutting edge efforts in the early 1980s, when a Duke University team determined that although MRI was faster, ultrasound was the closest to “achieving 3D real time acquisition.” The researchers, led by Dr. Olaf von Ramm, developed a single-transmit, multiple-receive ultrasound scanner called Explosocan to increase data bandwidth.

Elastography
One of the most revolutionary technologies in ultrasound consists of elastography, which utilizes B-mode ultrasound to measure the mechanical characteristics of tissues, which are then overlaid on the ultrasound image. This provides physicians the ability to view stiffer and softer areas inside of tissue, with image quality and clinical outcomes equivalent to X-Ray, MRI, and CT.
Elastography techniques include strain elastography and shear wave elastography (SWE). It has begun proving its use in the characterization of thyroid nodules, lymph nodes and indeterminate breast lumps as well as the detection of prostate cancer. None of these were achievable via conventional ultrasound.
The application which has generated maximum attention is liver fibrosis staging. Biopsies are not only invasive but carry bleeding and infection risks. Elastography, which can be repeated as often as required, is being seen as a way to get the data needed by clinicians to diagnose and stage liver diseases without the associated complications. Elastography is also used to predict complications in patients with cirrhosis.
SWE in particular is also seen as a tool to assist in earlier detection of conditions such as Hepatitis C, and both fatty liver and alcoholic liver disease. Alongside lab studies, it offers a means to closely monitor the impact of treatment and assess if the liver will normalize. For many hepatologists, fighting a liver condition before Stage 4 cirrhosis provides a good chance of reversibility.
SWE can also provide information on which Hepatitis C patients might benefit from viral therapy.

From smartphone apps to AI: the future
App-based ultrasound have recently been showcased. These use transducers connecting via a USB port to a mobile device and a downloadable app. The transducer performs data acquisition, processing and image reconstruction. The result is an ultrasound feature in a consumer-grade smartphone.
Some vendors have launched artificial intelligence systems to enhance speed and automatically take image volume data from 3-D echo to recreate optimized diagnostic views. In cardiac echo in particular, the result offers major potential by permitting reproducibility of imaging.
Nevertheless, such cutting edge technologies are still in their infancy. Only time and user experience will determine their eventual success.

At the European Society for Breast Imaging (EUSOBI) meeting last September in Berlin, Hologic officially launched the 3Dimensions™ mammography system which offers a variety of groundbreaking features designed to provide higher quality 3D™ images for radiologists, enhanced workflow for technologists, and a more comfortable mammography experience, with low-dose options, for patients (see featured item).
On this occasion, International Hospital talked to Lori Fontaine, Vice President of Clinical Affairs for Hologic.

Is the launch at EUSOBI only for Europe or is it global?
The 3Dimensions™ mammography system received CE Mark in July 2017 making it commercially available in EMEA, followed shortly thereafter by the U.S. launch in August 2017.

Can you give some details and figures on dose reduction for the new system?
We know that dose is a common concern across Europe, and the 3Dimensions system helps address this by providing low-dose options for patients, among many other benefits. The 3Dimensions system results in a 45 percent dose reduction with a generated 2D image compared to 2D FFDM alone. 

Is the improvement in image clarity regardless of breast density likely to reduce the need for a secondary ultrasound in the screening of high density breasts?
We already know the 3Dimensions system’s Clarity HD high-resolution 3D™ imaging reduces recalls by up to 40 percent compared to 2D alone, and given Clarity HD works to deliver exceptional 3D™ images, regardless of breast size or density, it makes sense that the 3Dimensions system would be an ideal option for women with dense breasts. This is especially true since the 3Dimensions system operates in tandem with Hologic’s 3D Mammography™ exam, the only mammogram approved by the U.S. Food and Drug Administration as superior for women with dense breasts compared to 2D alone, which further demonstrates that tomosynthesis should be the standard of care for women across the globe when it comes to breast cancer screening.

Do you have any information and figures on the adoption rate of DBT by radiologists in the various European countries, are there significant country variations (or regional between US, Europe and Asia)?
Digital Breast Tomosynthesis (DBT) adoption rates vary by country. While DBT has been approved in EMEA since 2009, the majority of EMEA countries limit the use of DBT to diagnostic imaging as they have concerns regarding dose and reading time. Hologic remains at the forefront of technology innovation and is working to overcome these barriers, so that all women can be screening with DBT.

Hologic was the first company to receive FDA approval for DBT use in both the screening and diagnostic setting in the U.S. in 2011. Today, DBT is used in approximately 40 percent of all U.S. screening mammography exams and is covered by the majority of insurance companies. The evidence of the benefit of Hologic’s 3D Mammography exam as a better mammogram continues to expand and resulted in the addition of DBT to the National Comprehensive Cancer Network (NCCN) Guidelines in 2016. NCCN is recognized globally as an alliance of 27 U.S. cancer centers that develop recommendations designed to help healthcare professionals diagnose, treat and manage cancer care.