Medical Solutions December 07 RSNA

Medical Solutions
The Magazine for Healthcare Leadership

December 2007
Beyond Technology
Futurist John Naisbitt on Innovation
Breast Cancer
Comprehensive Solutions
What if workow met innovation at every turn?
Our latest breakthrough technologies streamline your clinical processes. Innovating every step of your workow.
Its 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
Answers for life.

CC-Z1039-1-7600
Editorial
Innovating Every Step of Your Workow
Erich R. Reinhardt Member of the Managing Board of Siemens AG, President and CEO of Siemens Medical Solutions
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 Hospital of Munich, during this years ISSSR*. We are convinced that efficient workflow throughout the entire continuum of care, from early detection, diagnosis, and therapy, to follow-up, is one of the most relevant economic success factors in healthcare in order to improve quality of care
and to achieve financial success. In this context, Healthcare IT solutions are essential. This is illustrated, for example, by the recent introduction of Siemens Pharmacy 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 documentation 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 continuum 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 administrative 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-magazine
Content
Content
Cover Story
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Remote Solutions: Imaging and Viewing from Beyond
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Facility Planning: Patient and Personnel Needs
3 10 Innovation Development In todays 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 Divisions about how the latest innovations came to being. And we spoke with futurist John Naisbitt about innovation and its adoption in the healthcare sector.
Editorial News Further Reading Feedback Trade Fairs Imprint Subscription
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Content
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Image Management: Pediatric Cardiology
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Virus Protection: Safety Net for Online Threats
Features
25 Comprehensive solutions help streamline breast cancer management, from early detection to diagnosis, treatment, and follow-up. 52 Leveraging on Siemens broad capabilities in healthcare and infrastructure and on Portugals hospital system reform, private healthcare operator Esprito Santo Sade opened a completely digitized facility. 78 Integrated RIS/PACS is a lever to increased efficiency, lower operational cost, and improved patient care.
36 A web-based electronic health record will link up all of German RHN-KLINIKUM AGs 46 facilities to enhance the quality of care delivered to more than one million patients seen annually by the group.
58 Two top childrens hospitals in the US Midwest have optimized patient care by implementing digital imaging workflows and reporting in their cardiology departments.
84 When expanding and redesigning its Cancer Center, US-based Susquehanna Health focused on patient needs and workflow requirements.
40 In pursuit of business opportunities, the private Swiss Sonnenhof Hospital is engaging in research for hip impingement arthritis.
90 Siemens protects hospitals imaging systems against viruses, worms, and Trojan horses.
66 A 20-minute magnetic resonance exam replaces several separate examinations in cancer staging and treatment planning.
96 Perioperative abdominal imaging heavily relies on precision and ease of use.
46 Two solutions enable remote access to detailed 3D/4D information and allow system control from, for example, the office.
70 New tools ease physicians work for effective therapy control and follow-up of cancer.
News
Argus 4D VF allows left ventricular function assessment in less than a minute and provides advanced 4D visualization of the beating heart.
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 consoles or manual postprocessing of contours. The heart is localized on MR images automatically; the system helps detect the inner and outer contours and generates the functional data
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 myocardial scars, to clarify thoracic pain (stress MRI), to evaluate congenital heart diseases, as well as to plan ablation in electrophysiology. MR images of cardiac functions, coronary vessels, and congenital heart defects can also be acquired three-dimensionally. The Inline VF software is available for 1.5 Tesla and 3 Tesla MAGNETOM scanners.
Portable and Secure Access with the Patient Health Card

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. Healthcare providers can benefit from the technology 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 identification card, which may contain patient information such as: medical history, chronic diseases, allergies, current medications, lab results, demographic data, and even insurance information. The patient must enter a personal identification 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 Institute 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 organizations, which may help to reduce errors and costs, and can improve healthcare quality.
The patient health card is a secure means of storing vital patient data and is easy for the patient to carry.
News
Diagnosing Faster, Safer

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 inconclusive. 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 (PETCT) scan to evaluate perfusion of the myocardium, and receive their results within one hour. Samuel H. Mehr, MD, Alegents Director of Molecular Medicine and Imaging, says: Studies* indicate that PETCT perfusion testing in these patients has more than 90 percent accuracy, compared to other noninvasive or nuclear medicine exams. Other than 18 F-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 clarifying which patients do not suffer from CAD is also beneficial for both the patient, who doesnt need diagnostic catheterization 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, PETCT 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.
The new generation of ARCADIS C-arms brings various new features to aid in clinical workflow.
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 generation of systems equipped with a brand-new ergonomic monitor trolley. With the latest advancements, healthcare professionals can profit from improved clinical workflow 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 postprocessing, and networking. To help further optimize workflow, convenient ergonomic features have been added. Electromagnetic brakes also help ensure fast and precise positioning.
Dr. Samuel Mehr and the staff at Alegent Health benefit from the workflow advantages provided by Siemens Biograph TruePoint PETCT.
News
Redefining PET Imaging with High Definition

In conjunction with the high-definition television trend that has transformed the entertainment world, Siemens has unveiled the worlds first high-definition position emission tomography (HDPET) molecular imaging system. The revolutionary HDPET technology promises superior detection of small lesions with high definition uniformity, resolution, contrast, and clarity. These advantages can aid in cancer diagnosis, disease staging, treatment, and postsurgery/postradiation monitoring. Siemens Medical Solutions introduced HDPET at the 2007 Society of Nuclear Medicine (SNM) Annual Meeting in Washington, DC, USA. The clarity achieved by HDPET can literally change the whole picture. The added contrast is a result of the high-definition technology. Michael Reitermann, President of Molecular Imaging, Siemens Medical Solutions, adds, The clarity of HDPET 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, HDPET provides distortion-free images throughout the entire field of view. Thanks to a two-millimeter resolution, 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. HDPET is available as part of Siemens TruePoint technologies a unique combination of technological features and workflow solutions for PETCT imaging to help better diagnose and treat patients. The high-definition feature will not only be available on all new Biograph TruePoint PETCT systems, but also as an upgrade option for current Biograph TruePoint users.
Thanks to its two-millimeter resolution, HDPET (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 Patients

At 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 hospitals 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 reductions 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 challenges 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 Childrens 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.
The University Hospital works to improve patient throughput without jeopardizing quality care or budget concerns.
Versatile New Monitor

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 reliable gray-scale response and continuous luminance levels. The display can also be used with the latest standard, high-performance 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
The new monitor provides reliable grayscale images and can continuously monitor luminance levels.
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 environment. 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.
Innovations
Innovating Every Workflow Step

At this years Radiological Society of North America Annual Meeting, Siemens introduces its latest crop of new and exciting products. All are designed to ll the needs of customers in todays climate of rapid technological change and workow improvements, and are adaptable to serve them well into the future.
By Haig Simonian
To say that innovation is an essential part of Siemens seems like stating the obvious. This, after all, is the company that introduced the worlds first X-ray tube, the first commercially available ultrasound system with real-time display, the first instant image generated by computed tomography (CT), and the first common user interface 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 publicsector healthcare providers or privatesector 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) Division 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 providing 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 interventional suite, explains Gaus, an electrical engineer who has spent much of his career in research, especially in information technology. 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 traditional 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 Divisions SOMATOM Definition era system, a 2007 RSNA debut building on the breakthroughs of the first SOMATOM Definition product two years ago. This is the worlds first adaptive scanner. It can be matched to any patient, including those who might have been difficult to scan before. This is what I call the transition from almost to always, says Montag, describing the systems 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.
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Innovations
* 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.
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 endovascular or cardiovascular procedures. During emergency situations, 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.
We support our customers by specically developing products and solutions that increase the quality of healthcare and preferably simultaneously lower its cost.
Norbert Gaus, President, Angiographic, Radiographic and Fluoroscopic Division, Siemens Medical Solutions, Forchheim, Germany
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 workflow for staff. It is the most exciting equation 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 Mrzendorfer, Head of the MR Division. But offering a first-ever, 70-centimeter 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. Weve 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. Mrzendorfer, who formerly led development 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 equipment. 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-
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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 attainable for many hospitals and practices that simply cant run it today. MAGNETOM ESSENZA represents a paradigm shift. It could change the market, Mrzendorfer predicts. The key lies in the fact that Siemens put many innovations together,
including Tim, that allow combining excellent 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 weve got to find ways to make MR more affordable for new users. Whether in AX, CT, MR or other key Divisions, all new Siemens products reflect intense interaction between the companys
research and development and marketing staff with key customers. For Klaus Hambchen, 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, Hambchen and his teams invite about 100 ultrasound power users and key customers a year to visit the Siemens Ultrasound Innovation Center 13
Innovations
MAMMOMAT Inspiration: Increasing Mammography Acceptance With MAMMOMAT Inspiration*, Siemens is developing a product platform for mammography with the goal to combine technical 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 workflow efficiency for screening as well as excellent image quality at low dose in mind. An equally important aspect in its development is patient well-being and thereby increasing the acceptance of the screening process. Backlit MoodLight** panels are planned to support MAMMOMAT Inspiration providing a mammography environment with the aim to help alleviate patients fears and improve the diagnostic centers image. In addition, it shall represent a technology platform that opens customers a smooth upgrade pathway from todays configuration to future three-dimensional mammography with tomosynthesis*.
** 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.
We want to optimize everything from how you conduct an examination 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
and discuss how the Divisions products can be further improved. This is where we gain a lot of direction and perspective about the clinical priorities, says Hambchen, 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 promising, 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. Hambchen 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 innovation in ultrasound has been slow over the last ten years. This is why were focusing on reestablishing ultrasounds credentials by introducing a new generation ultrasound platform that will be offering unprecedented customer demand fulfillment. The ACUSON S-Class, making its debut at RSNA, breaks new ground in the specificity of ultrasound with the introduction 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 Hambchen: 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
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Innovations
Jochen Dick
Head of Special Systems Division at Siemens Medical Solutions
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
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 Hambchen of Ultrasound. With these specifications in mind, the engineers designed an ergonomic 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 Divisions first such product to be conceived from the start for the digital era, with its design brief focusing on streamlining throughput while maintaining 15
Innovations
ACUSON S-Class: Acoustic Mastery The ACUSON S2000 ultrasound system is the first product of the new Siemens next-generation ultrasound 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 diagnostic capabilities and outcome beyond the traditional roles of ultrasound. In addition, the ACUSON S-Class next-generation ultrasound systems are Silicon Ultrasound enabled, making them ready for true isotropic volume imaging, previously the domain of magnetic resonance imaging (MRI) and computed tomography (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.
* 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.
Customer contact is where we gain a lot of direction and perspective about the clinical priorities.
Klaus Hambchen, President, Ultrasound Division, Mountain View, CA, USA
image quality. Take a high-volume screening 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. Dicks one-click technology means simplifying 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 everything from how you conduct an examination 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 physician 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 matter how great the quality improvements. Take mammography, he says. Invest-
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Innovations
Klaus Hambchen
Head of the Ultrasound Division at Siemens Medical Solutions
ment decisions are highly influenced by quality and patient friendliness. But workflow is the most significant differentiator in our field. Helping customers make the right investment decisions is central to what Siemens can offer; irrespective of whether X-ray, computed tomography, magnetic resonance or ultrasound is concerned. Obviously, every setting is different, says Dick.
The country, precise location, throughput, 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 practices or physicians partnerships than for massive teaching hospitals, but Mrzendorfer of MR says it is just as relevant for large departments acquiring multimillion 17
Innovations
SOMATOM Definition AS: Adapting CT to Clinical Needs 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 clinical 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 procedure time.
* 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.
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 seeking 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 importance on each individual customers needs, he says. That can start with help on planning everything from the positioning 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 turnkey maintenance but even, where technologically possible, real-time fault prevention. 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 somethings amiss, we automatically 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 Mrzendorfer of MR. None of our competitors have anything like it, adds Gaus of AX. With the Utilization Management service, we can even offer benchmarking, allowing customers to see how they are performing compared with others in similar settings. That can help them fine-tune their procedures in case there is room for improvement, notes Mrzendorfer. While the new Siemens systems represent the
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Innovations
Bernd Montag
Head of the Computed Tomography Division at Siemens Medical Solutions
pinnacle of todays technology and promise 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
hospitals picture archiving and communications system (PACS) with every new generation of equipment is an oftenmentioned 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 packages and service contracts to help them benefit from the latest workflow improvements, clinical applications, and diagnostic functions, says Gaus of AX. Building in flexibility to allow technological updating is a prime design criterion. Whether software or hardware, when we 19
Innovations
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 affordable* all-new 1.5 Tesla system that also offers the benefits of the latest Siemens MR technology, with its clinical applications and high throughput, to customers with lower budgets who want to enter the realm of MR imaging. The system was developed from the ground up to be an affordable, reliable powerhouse, and is packed with innovations to support both clinical and financial success. These innovations include a brand-new, ultra-light, small footprint 1.5 Tesla magnet, 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, its not just the purchasing price that makes the system affordable, but also its low installation and operating costs and workflow advantages, which all join forces to maximize revenue.
* Results may vary. Data on file.
MAGNETOM Verio: The Most Exciting Equation in MR Imaging On the ultra-high field side, Siemens introduces MAGNETOM Verio, the worlds 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 highend 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 acquisition 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 anxietyrelated movements lead to better image quality; patient access is improved for both intensive-care patients and MRIguided interventional procedures; and kinematic studies can be performed.
Whether software or hardware, when we make changes, we try to ensure everybody has a migration path to the next level.
Walter Mrzendorfer, 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 Mrzendorfer. 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 supporting this effort. Mrzendorfer draws attention to his Divisions Tim technology,
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Innovations
Walter Mrzendorfer
Head of the Magnetic Resonance Division at Siemens Medical Solutions
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 institutes, 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.
Further Information
www.siemens.com/rsna www.siemens.com/ AXIOM-RSNA-2007 www.siemens.com/ SOMATOM-RSNA-2007 21
Haig Simonian is the Switzerland and Austria correspondent for the Financial Times.
Innovations
Discovery isnt Enough

John Naisbitt, an American who has lived in Europe for the past eight years, is one of the worlds most renowned futurists. Medical Solutions interviewed him at his apartment in Vienna, Austria.
By Haig Simonian
Naisbitts 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 current 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 understand the word innovation? NAISBITT: I associate it with the evolutionary development of technical knowledge. I dont think there will be a next big thing, as the media sometimes suggests. Thats just hype. Were deeply into an evolutionary era, similar to the one in the 20th century. Looking, as I do, at all the timelines covering very many years, it appears that great breakthroughs and certainly technological ones come in clusters. We get these clusters, and then we spend a very long time extending and perfecting what weve 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. Were still working on the airplane; were still working on all of them.
Whats in the latest cluster? NAISBITT: At the start of the present century, its been information technology, biotechnology, and nanotechnology. Were going to spend most of the 21st century evolving what were discovering now. Its just beginning. Were on the edge of so many things. Even with IT: The Internet was a great breakthrough, but its still primitive. I think 40 years from now, well look back and say it was primitive. Likewise in biotechnology. Has the concept of innovation changed over time? NAISBITT: Obviously, the idea of new is invariably bound to innovation. But it hasnt always been linked to what Id call hard developments. How innovative was the language and construction of James Joyces Finnegans Wake? Or certain structures in poetry? But certainly, were now in a technological era, and thats 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 todays Apple iPhone. Its nothing really new, but whats striking about it is that it has put three existing technologies together. That perfectly illustrates the evolutionary era were in. And, turning back to the Chinese, I can tell you: The new China has got the idea now. Lets turn to business. For companies, is innovation the key competitive factor? NAISBITT: Theres a very good reason why todays mantra in business is growth through innovation. Its because were in a period of evolution, full of opportunities and chances to enhance whats been done before. Its the innovative companies that are going to have the edge over their rivals. But just discovering something isnt enough. Its the skill to be able to refine, enhance, and apply that will count. So its 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
23
Innovations
John Naisbitt (left) with author Haig Simonian (right)
the innovation, for example, of online orders and reservations. The airlines are really struggling with this, but no ones got it quite right yet. We tend to forget that innovation in service is as important as purely technological product breakthroughs. 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 developments. 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 handicapped athletes to run in races is extraordinary. 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, antibiotics have prolonged the lives of uncounted millions, from the great to ordinary 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 consequential 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 Alzheimers or Parkinsons also allows us to have progeny that are taller, smarter, faster, more beautiful or whatever, and no one is talking about it. So not all innovations are good?
This touches on the question of our relation to technology. Its 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 within the habitat, but human beings unquestioningly 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 replaced? Our relation to technology is the most unexamined relationship we have. Are you at all confident that were starting to ask such questions? NAISBITT: No, Im not. Weve 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 happen more slowly than we imagine. It is the surprises, like AIDS or 9/11, that overwhelm us.
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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
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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 PETCT (previous page).
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Breast Cancer
The radiology suite is moving towards a completely digitized environment, with the best offering integrated imaging systems 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 monitoring. The following article takes a comprehensive look at current innovations and new developments on the horizon.
sound Elasticity Imaging can be effective after an unclear mammogram and conventional 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 cancer was picked up, she says. You cant 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. Battlefields 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 centers 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 womens health imaging away from the rest of the center offers women the privacy they need. Placing all breast imaging 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 volunteers are proud of their comfortable waiting rooms, relaxed and private areas to discuss results, and the fact that they provide patients with nontraditional, patterned 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-
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 stomach 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 radiation, 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 mammography 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 todays comprehensive imaging solutions such as breast MRI been available earlier, Robertsons breast cancer might have been detected sooner, when it was more curable and less likely to spread. With todays technology, the door might have swung open to more effective treatment for her. Siemens MAMMOMAT NovationDR fullfield 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, todays ultra* Pisano et al., Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening, N Engl J Med. 2005;353.
You cant imagine how well they treat people here and what a good feeling it is to know that you are being diagnosed with the most current tests.
Barbara Robertson, Patient and Volunteer, Battlefield Auxiliary Breast Center, Ringgold, GA, USA
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Breast Cancer
The time that we are able to dedicate to patient care is greatly owed to the fast and easy workow at the systems themselves as well as when reading images and dictating results.
John F. Nelson, MD, Medical Director, Battlefield Imaging, Ringgold, GA, USA
Offering a panoply of the latest imaging modalities is crucial for optimizing breast cancer care, according to Dr. Nelson.
state (Georgia, Tennessee, South Carolina) area to offer full-field digital mammography 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 Chattanooga [Tennessee] or Atlanta [Georgia]. The availability of cutting-edge imaging and tender loving care has also attracted 28
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 Battlefields continued success. Center administrators are proud to be the first community center in their area to have the MAGNETOM Espree Open
Bore MRI system with Tim (Total imaging matrix) technology. Other equipment includes a syngo Opdima upright stereotactic biopsy system, an ACUSON Sequoia ultrasound system, and a Biograph TruePoint PETCT (positron emission tomography-computed tomography) scanner. According to Nelson, use of the MRI scanner has soared so much that the center 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 foresees 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
and are among those who test positive for the BRCA1/BRCA2 gene mutations.
Accelerated Workow
Battlefields 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 communication system (PACS) solution has resulted in numerous efficiencies, for example, in scheduling patients, performing the examination, interpretation, reporting, and archiving of patient data, including examinations performed on different modalities 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 comfortable 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 systems 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 nations Top Imaging Centers of Excellence 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 treatment 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 35
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. Medical Solutions December 2007 www.siemens.com/medical-magazine
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30
Breast Cancer
Early Detection
Diagnostics
Therapy
Aftercare
seek
find
act
Molecular Imaging
Biograph TruePoint PETCT TruePoint SPECTCT
follow
Mammography
MAMMOMAT Novation
Mammography
MAMMOMAT Novation syngo Opdima MammoTest
Mammography Ultrasound
MAMMOMAT Novation
CAD Ultrasound
High-frequency Imaging 2D Beam Steering
syngo MammoCAD*
Ultrasound
Ultrasound Oncology Care Solutions

ARTISTE* syngo Suite for Oncology eSie Touch Elasticity Imaging Fatty Tissue Imaging Cadence Contrast Pulse Sequencing Technology (CPS) Native TEQ tissue equalization technology
Cadence Contrast Pulse Sequencing Technology (CPS) Automated Breast Scanning (ABS)
Automated Breast Scanning (ABS) Advanced SieClear Spatial Compounding
Magnetic Resonance
syngo VIEWS syngo GRACE Tim technology syngo Chorus
Magnetic Resonance Molecular Imaging

Biograph TruePoint PETCT TruePoint SPECTCT syngo VIEWS syngo GRACE Tim technology syngo Chorus
Magnetic Resonance
syngo VIEWS Tim technology syngo BRACE syngo Chorus
Computed Tomography
SOMATOM Definition AS syngo CT Oncology
Magnetic Resonance
syngo VIEWS syngo GRACE Tim technology syngo Chorus
In vitro solutions
CEA, CA 15-3, and BR 27.29 HER-2/neu
Molecular Imaging
Biograph TruePoint PETCT TruePoint SPECTCT
Computed Tomography
SOMATOM Definition AS syngo CT Oncology
In vitro solutions
CEA, CA 15-3, and BR 27.29 HER-2/neu
*Not available for sale in the USA.
*Not available for sale in the USA.
Breast Cancer
Medical experts from the USA, Germany, Belgium, France, Netherlands, and Japan talk about the latest Siemens innovations for breast cancer.
DETECTION / seek
CAD in Mammography
Computer-aided detection (CAD) software offers radiologists a second look at lesions that might otherwise be missed on full-field digital mammography. CAD algorithms are written to identify specific cancer morphologies. 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 radiologists 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 finding 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 especially 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.
syngo MammoCAD* marking a suspicious lesion for further review a mass and a cluster of microcalcifications
* Not available for sale in the USA.
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, according to Andr-Robert Grivegne, MD, who has been using the scanner for about a year. Its automation feature cuts nurse and physician time in half, notes Grivegne, Professor and Clinical Chief of Breast Imaging at the Institut Jules Bordet in Brussels, Belgium. With conventional 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 dont perceive the exam as aggressive, says Grivegne. Another advantage, he notes, is that all of the data are stored, allowing radiologists to review the information later.
Coronal view of a breast cyst identified with SomoVu Automated Breast Ultrasound System distributed by Siemens Medical Solutions December 2007 www.siemens.com/medical-magazine
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Breast Cancer
DIAGNOSTICS / find
Elasticity Imaging
Much research and development in breast imaging is geared toward developing devices that offer increased specificity. eSie Touch Elasticity Imaging is a promising, novel technique under study. Richard G. Barr, MD, PhD, Professor of Radiology at the Northeastern Ohio University College of Medicine and Radiologist at the Southwoods X-Ray and MRI in Youngstown, OH, USA, describes how it works. An elastogram differentiates relative hardness and softness of tissue, he explains. Initial findings indicate that elasticity technology has
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 offering 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 specificity. Elasticity Imaging was tested in a population of 80 patients with 123 suspicious 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
Biopsy-proven invasive ductal carcinoma as detected with eSie Touch Elasticity Imaging area of stiffness in black
adjunct to other breast imaging techniques. Currently, a multicenter trial is underway at three facilities located in Europe (London, Paris), Australia (Brisbane), and several sites in the USA.
Breast Spectroscopy, syngo GRACE

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 mammography, 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 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 conventional 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 spectroscopy application syngo GRACE. With syngo GRACE, choline can be detected in breast cancers, which is considered an indicator of the activity of breast neoplasms and the viability of breast cancers. Therefore, Siemens breast MRI spectroscopy, 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 repositioning. Spectroscopy acquisition takes between five and seven minutes, whole-body imaging with MRI 35 minutes, and for MRI plus MRI spectroscopy, its 40 minutes. Acquisition with Tim is totally automatic, Tozaki says. I am also very positive about using MRI after chemotherapy for monitoring.
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
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Breast Cancer
PET-MRI: Improving MRI Specicity

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 Medicines Department of Radiology, have been evaluating whether images from Siemens PETCT, when fused with MRI images from the departments Siemens MRI systems, yield added specificity to breast MRI. For the PET exam, they used a prototype 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 combined 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 percent respectively. When MRI and PET were fused, the sensitivity declined to 83 percent, while specificity increased to 95 percent. An additional 14 patients have been studied since, and the pooled analysis confirms the initial results.
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.
Lymphoscintigraphy
When 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 cant go back to a [Toyota] Camryits 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 SPECTCT, (single photon emission computed tomographycomputed 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. Whats 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. Eliminating 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 SPECTCT imaging, further research is imperative.
99 mTc-Sulfur Colloid SPECTCT lymphoscintigraphy performed on a patient with primary breast carcinoma accurately localizes two sentinel lymph nodes in the axilla for further biopsy.
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Breast Cancer
Staging with SOMATOM Denition AS

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 worlds 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 CTguided ablation therapy procedures. Bautz notes that the new systems 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 physicians opinion.
* 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.
CT-guided ablation therapy for a metastatic lung lesion
THERAPY / act
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 JeanPierre Lotz, MD, Chief Medical Oncologist at Universit Pierre et Marie Curies Hpital 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.
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Breast Cancer
Adaptive Radiation Therapy

Adaptive Radiation Therapy (ART) is designed to provide feedback to the radiation 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, Netherlands, is impressed with the ARTISTE* Solution from Siemens, the next generation in ART. You are able to set up the beam so that the heart and lungs are not
* Not available for sale in the USA.
in the radiation field, he says. Innovative In-Line imaging technology allows clinicians to tailor radiation therapy to the patients 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 perpendicular 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 ARTISTEs built-in flexibility, he says, we do not need to immobilize the patient with a special frame for stereotactic radiotherapy. 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 homogenous. 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
Looking Forward, Looking Back

When radiologists in the future look back on the evolution of breast imaging within the last 40 years, they will see that mammography opened an entirely new field. Analog mammography was the first imaging 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 forever changed early detection proved an achievable goal. Eventually, though, the limitations of analog mammography caught up with it: There was a high falsenegative rate and difficulty imaging young women and those with dense breast tissue. Mammographys functionality was also limited. Women disliked its harsh compression, 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 collaborators and customers have stepped up to the plate to develop new solutions in this critical area of healthcare. As a result, todays screening systems are less intimidating 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 enhance 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 screening. Hybrid devices, such as Symbia TruePoint SPECTCT, build on the strengths of their individual components, 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.
Laura Newman is an award-winning medical writer based in New York, NY, USA. She is the author of numerous feature articles about emerging medical technologies. She was also the editor of Medical Outcomes & Guidelines Alert, a newsletter widely read by the pharmaceutical and medical device industry.
Further Information
www.siemens.com/breastcare www.changethestatistic.com
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Electronic Health Record
Dietmar Pawlik (right), Board Member of RHN-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.
Trendsetter in eHealth
The introduction of the electronic health record at 46 hospitals of RHN-KLINIKUM AG is the largest privately-nanced IT project in the German healthcare industry and may send an international signal.
By Notker Blechner
Dietmar Pawlik, an acting Member of the Board at RHN-KLINIKUM AG, and Volker Wetekam, President of Global Solutions Division at Siemens Medical Solutions, are the two managers responsible for introducing the electronic health record (EHR) at the hospitals of RHN-KLINIKUM AG. In an interview with Medical Solutions, they explain the benefits and challenges of the joint project. RHN-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 hasnt the digital age reached the healthcare industry by now?
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Our goal is to integrate other hospitals using different systems to provide services.
Dietmar Pawlik, CFO, RHN-KLINIKUM AG, Germany
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 treatment reports, can be stored digitally and exchanged between hospitals. This will, for example, reduce unnecessary examinations 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 savings are far greater than the costs associated 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 RHN-KLINIKUM AG doing to promote the electronic health record? PAWLIK: We started thinking about digitizing 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 RHN 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 situation. 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 mechanisms: 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 development and enhancement of the electronic health record, and are working together
PAWLIK: Digitization in hospitals is far more advanced than one may think. Many treatment processes are supported digitally to a much greater extent, however, in diagnostics than in process organization. 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 electronic health card represents a change in medium not in structure.

Volker Wetekam, President of Global Solutions Division, Siemens Medical Solutions, Erlangen, Germany
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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 RHN-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 RHNKLINIKUM AG is very important to us. It is our closest and most strategic cooperation worldwide. We see RHN hospitals as the ideal partner, not only because they practice excellent medicine, but also because they are efficiency-oriented.
technology because their dealings with patients would be much more visible than before. Now, however, most physicians recognize the benefits. Practical experiences during the pilot project have even resulted in a fascination for the technology among some of them. They enjoy participating in the project because they have seen that the record improves their performance. What is the economic importance of the EHR project? WETEKAM: Through digital integration of the hospitals of RHN-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 RHN-KLINIKUM AGs 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 RHN-KLINIKUM AG. Discussions are currently underway with Lich Hospital, near Frankfurt am Main, Germany, which is not part of the RHN group. We have a good chance of becoming the standard platform for the electronic health record in Germany. Arent you being a bit optimistic? The German healthcare system does not have a uniform standard for electronic health records
PAWLIK: RHN-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 implemented. At the moment, we are building the Center for Particle Therapy for 120 million in Marburg, Germany, with Siemens as the technology supplier. Our cooperation 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 investigating the development of a knowledge database for stroke patients. WETEKAM: In the final project phase, we want to use the record as a knowledgebased medium. It certainly helps that RHN-KLINIKUM AG has scientific partners such as the German University Hospitals of Marburg and Gieen working with it. Was there any skepticism or resistance to the project from patients or physicians? WETEKAM: There was no general skepticism 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
The objective is to offer interoperability across sectors and providers.

Dietmar Pawlik, CFO, RHN-KLINIKUM AG, Germany
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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 interfaces like HL7, we will continue develop-
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 interoperability across sectors and providers. When the clinics of RHN-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 project 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
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 importance of IT in the healthcare industry more than ever before.
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).
Further Information
www.siemens.com/ehealthsolutions
The Electronic Health Record (EHR)

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, healthcare 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. According to the German Federal Health Ministry, 10 to 20 percent 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 RHN-KLINIKUM AG together with Siemens. The WebEPA will be implemented in all 46 clinics of the RHN-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.
The Electronic Case Record (ECR)

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, RHN-KLINIKUM AG is cooperating with German Asklepios Kliniken, Sana Kliniken GmbH & Co. KGaA, public institutions, and the Fraunhofer Institute for Software 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.
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The reception area of the Radiology Department at Sonnenhof Hospital Berne reminds visitors more of a trendy hotel than a medical department.
Research in a Niche Market

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 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 examination plans glow on the screens in the hallway, showing that the diagnostic work in the hospital is precise, quick, and standardized. We have modernized the department 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 hospitals key stakeholders, investments into the infrastructure 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 platform technology, Tim (Total imaging matrix) provides ideal prerequisites: flexi-
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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 examinations 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-
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ticipating in research projects that show the considerable potential of the new MRI system generation. Their initial results indicate that the predictability of a successful 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 technologies will certainly benefit from these developments, says Werlen. He hopes for his department that the high quality standard 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 resolution and speed of examination provided
by Tim. This applies to the use of MRI in orthopedics, for example, when examining hip arthrosis, says Stefan Werlen. In many cases, only hip surgery shows that the articular cartilage has just about disappeared 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
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the cartilage has been destroyed. If enough cartilage is available, joint preserving treatment can be initiated.
Summary
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
Attractive Market Niche

Because the radiology team at Sonnenhof 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 diagnoses, 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 evaluation software is as easy as possible. This saves time and money and provides enough breathing room for a sometimes time-consuming diagnosis, which is important in the interest of optimal service.
The rise in demand justies the investments in the infrastructure of our department.
Stefan Werlen, MD, Head of the Radiology Department, Sonnenhof Hospital, Berne, Switzerland
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 preventive approach is of major importance: The study should detect the risk for serious, long-term hip damage early enough to
cartilage. It seems intact on the X-ray image, although the contents of proteoglycans have already decreased and therefore the cartilage structure is damaged. But syngo MapIt, a sequence and postprocessing package for quantitative MRI assessment, provides approaches to assess proteoglycan decrease before surgery. With the help of this software, the deficit of proteoglycans is visible onscreen. The radiologist is able to provide the orthopedist 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
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determine who will most likely require an artificial hip joint sometime in the future. If it is possible to determine the adolescents 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 economic 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 impingementinduced arthritis to athletes. It is known that certain types of sport activities frequently 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 impingementinduced arthritis. The causes for their accumulated occurrence in athletes are vague at the moment, says Werlen. The scientists assume that during the adolescence of athletes, certain movements interfere with bone growth in the joints, which in turn are responsible for impingement-induced arthritis.
The Road of a Private Hospital

Stefan Werlen suggests another diagnostic 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 technology 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 diagnosing 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 falsepositive 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 hospitals economic point of view, this opens up interesting possibilities, believes Werlen. The example from orthopedics and the potential of prostate examinations clearly demonstrate that modern MRI equipment with Tim technology 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.
Oliver Klaffke is a scientific and economic journalist. He writes for Nature, New Scientist, and Bilanz, a Swiss business magazine.
Further Information
www.siemens.com/ MAGNETOM-1-2007 www.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
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Remote Solutions
Associate Professor Anders Persson, MD, Director of the Center of Medical Image Science Visualization (CMIV), Linkping University Hospital, Sweden, appreciates the improved workflow with syngo WebSpace.
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Remote Solutions
Direct Line to System or Data

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 workows.
By Katja Stcker, MA
Lets take a closer look at the vessels, says Bernd Wintersperger, MD, Associate Professor of Radiology and cardiac imaging expert at the Department of Clinical Radiology of the University of Munich Hospital (Grohadern Campus), Germany. At the 12th International Magnetic Resonance Imaging (MRI) Symposium in Garmisch-Partenkirchen in Germany, Bernd Wintersperger takes over the mouse control and does this demonstration scan via online access from a regular computer at the speakers 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 GarmischPartenkirchen 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 application has proven itself in clinical use. For example, when younger colleagues have a question for experienced colleagues regarding a special examination, the experienced 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 within the hospital network. Then they can consult and perform the scan. Access is possible from a computer or laptop*, the
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), Linkping University Hospital, Sweden
* Computer/laptop must meet minimum requirements.
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Bernd Wintersperger, MD, Associate Professor of Radiology and cardiac imaging expert at the Department of Clinical Radiology of the University of Munich Hospital (Grohadern Campus), Germany, explains the possibilities of syngo Expert-i at the 12th MRI Symposium in Garmisch-Partenkirchen, Germany.
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Remote Solutions
console of a picture archiving and communication system (PACS), or from any other MRI system within the hospital network.
Certain Diagnosis and Improved Workow

According to Wintersperger, the application 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 Grohadern campus, the city campus colleagues 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 Grohadern. 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 Data on the Ofce Computer

Some 1,400 kilometers away from Wintersperger, Associate Professor Anders Persson, MD, also gets excited when he hears the phrase remote access. In contrast to his colleague in Munich, the Director of the Center of Medical Image Science Visualization (CMIV) at Linkping University Hospital in Sweden is thinking more along the lines of transferring 3D/4D image data directly from a CT scanner to a computer, laptop*, or PACS. Perssons 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.
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Remote Solutions
Summary
Challenge: Uncertainty during an exam Live scans at conferences and training courses Handling detailed data beyond the radiology department Improved planning for interventions 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 workstation 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 efforts syngo WebSpace Short-term storage of comprehensive thin-slice CT images Precise planning of surgical procedures and interventions Improved diagnoses and advice to patients
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 WebSpace, 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 simultaneously 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 interdisciplinary 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 workflow and intensive cooperation with clinical 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 researchers and 31 doctoral candidates focus on the big picture. Persson and his team are researching imaging and reconstruction, image analysis, visualization, and processing, as well as transferring of comprehensive 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 Hospital: 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
* Computer/laptop must meet minimum requirements. ** Internet connection needed.
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, simplifies my work and improves treatment for my patients. syngo WebSpace is also the optimal solution for short-term storage of thinslice CT data (less than five millimeters). Depending on the configuration, from 1.6 to almost 10 million thin-slice acquisitions can be stored on the syngo WebSpace server. The need for 3D/4D image data from volume CT images has grown enormously, but purchasing new or upgrading 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.
Further Information
www.siemens.com/syngo-Expert-i www.siemens.com/syngo-WebSpace
Virtual Autopsies Clarify Criminal Cases

One focus of the CMIV is cardiac examinations. The Dual Source SOMATOM Definition CT system provides Persson and
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Remote Solutions
his colleagues with high-resolution, realtime images of the beating heart, using a low dose of contrast agent and no beta blockers. Because of its modern equipment, the CMIV also works on solving criminal cases. According to Persson, since the centers founding in 2003, it has performed 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-resolution, 3D imaging provides fast, precise information on injuries and fractures. Using syngo WebSpace, the information is sent just as quickly to the corresponding police stations and district attorneys offices.
Remote: Benecial 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 Stcker works in the editorial office of Medical Solutions. Prior to this, she was a freelance 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 examinations, increase patient throughput, and allow for secure diagnoses.
Bernd Wintersperger, MD, Associate Professor of Radiology, Department of Clinical Radiology, University of Munich Hospital (Grohadern Campus), Germany
Siemens improves the workow in radiology and beyond with the two remote solutions syngo WebSpace and syngo Expert-i.
Order Plan & Prepare
Patient Preparation
Scan & Reconstruct

Scan Data (Remote access via syngo Expert-i within the hospital network)
Process
Read & Report
Distribute
MultiModality Workplaces + CT Clinical Engines + syngo Expert-i
syngo Expert-i (Remote) syngo WebSpace (Clients)
Office PC
Acquisition Workplace
CT/MR syngo Workplace WebSpace Server
Office Laptop
Shared Database
Fast Data Link
PACS Archive
PACS Reading Workstations
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A Sense of Elation in Portugal

The hospital system reform in Portugal has opened up a new market for private clinics. In Lisbon, private hospital operator Esprito Santo Sade 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
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The Portugese healthcare system is on the move towards private hospital investments.
We have realized a dream, says Ivo Anto. The Chief Information, Organization and Processes Officer (CIO) of the Esprito Santo Sade (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 Esprito Santo investment group, maintains 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, including more than 40 clinical specialties. In addition, as part of an Integrated Healthcare Complex, Hospital da Luz also comprises 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 Anto. 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 technicians 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
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Digitized Hospital
54
Digitized Hospital
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 percent 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 dangerous. Over the past four years, the number of privately insured persons has risen steadily. Physicians and hospital personnel complain of antiquated facilities and equipment. As part of the reforms, the government is relying on private management 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 interesting market for private hospital operators. 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 compared to other European Union (EU) countries. However, the government is increasingly opening the market to private initiatives. Through its subsidiary Esprito Santo Sade, the Esprito 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 companies in the country, the group has a significative 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 cooperation 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, numerous Siemens business units worked together 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 financial 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 company made the best offer in each area, says Anto. But integrating numerous
companies in such a large project would add an increasing degree of complexity and risk, according to the CIO. Should problems 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 Anto. As a result, almost the entire infrastructure 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 corporations 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, according to Anto. Previously, private hospitals found their market niche through better food, nicer rooms, and shorter wait times. Today, however, that is not enough, says Anto. In the private sector, the infrastructure of hospitals and rehabilitation facilities has to meet ever increasing patient requirements. In addition to having the best medical and nursing staff, modern communications 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
When looking at the integration of various information technologies, Siemens appeared to be the only company with the corresponding capacity.
Ivo Anto, CIO, Esprito Santo Sade, Lisbon, Portugal
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Digitized Hospital
Combining Soarian Health Information Management (HIM) and the HiMed Cockpit enables access to digital patient data directly at the bedside.
when looking at the integration of various information technologies, Siemens appeared to be the only company with the corresponding capacity, explains Anto.
Process Orientation Centered on the Patient

The IT, with solutions running from departmental 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 detecting sepsis, systemic inflammatory response syndrome (SIRS), and septic shock in patients. In principle, this pathological finding refers to out-of-control blood poisoning 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 patients bedside, simplifying work enormously. He sees
the HiMed Cockpit linked to the Soarian system as trendsetting. It is not only available 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 comfort. 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 magazines 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
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Digitized Hospital
With Soarian and the HiMed Cockpit system, we can immediately access patient data and medical records anywhere in the hospital, even at the patients bedside.
Jose Roquette, Director, Hospital da Luz, Lisbon, Portugal
Summary
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
system (Siemens DESIGO) to the scheduling 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 costeffectively and efficiently. In this regard, the modern communication systems from Siemens, as well as Soarian, help in streamlining internal workflows and in eliminating unnecessary work for all staff. The result: fast, patient-centered organization of work instead of siloed departmental thinking, Anto explains. This, in turn, results in shorter inpatient stays, better planning of ward workflows, less bureaucracy, and the elimination of expensive, unnecessary services, benefiting the hospital and its personnel, as well as the patients.
most modern private hospital. Accompanied by Portuguese Economics Minister Manuel Pinho and Antnio 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.
Manuel Meyer reports from Spain and Portugal as a correspondent for the Austria Press Agency (APA).
Further Information
www.siemens.com/healthcare
Portugals President Dedicates Hospital da Luz

Six months after opening in April 2007 is not enough time to make definitive statements 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 hospital as a symbol showing the way toward a new healthcare system. In April 2007, Portugals President, Cavaco Silva, was on hand to personally dedicate the countrys
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Image Management
Pediatric Cardiology Reporting Grows Up

Since the arrival of syngo Dynamics in their specialized cardiac facilities, two top childrens 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 benets 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 Childrens 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 customizable 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 department and to referring physicians in outlying 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 Childrens 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 instantaneously 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 Midwests 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

Childrens 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 childrens hospitals in the country by Child
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 threestate 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 hospitals Pediatric Echocardiography Laboratory. It defines anatomy, physiology, and hemodynamics for all patients. Its 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 pediatric cardiology, no two hearts are the same. They all have different congenital abnormalities that require specialized imaging techniques to identify the abnormalities, and specialized surgical techniques 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-
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you just did. For Childrens Hospital of Wisconsin, the road to the Siemens system was long and bumpy. We started out early with a vendor who provided digital archiving but didnt have a good reporting tool, Peter Frommelt says. Then we went to a different vendor who didnt 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 wed 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 collaboration has been very good, says David Organ, IT Project Leader for Childrens Hospital of Wisconsin. The tools we have that allow me to configure syngo Dynamics are far and away the best thing Ive seen in the industry. With the last picture archiving and communication system (PACS) we had, every time I made a configuration 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 Childrens Hospital of Michigan were considering 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 working 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 Childrens Hospital of Michigan, the reports also included autopopulated 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
Childrens 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
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 didnt 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 doesnt help anybody, says Peter Frommelt. In Detroit, doctors in the pediatric cardiac catheterization lab were facing a similar problem. Childrens Hospital of Michigan, part of the Detroit Medical Center complex, is the only freestanding childrens hospital in Michigan and the states leading 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 units 13 full-time physicians and 70 employees. At the center
of the cardiac unit is one of the nations 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 procedures 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 procedure. About 60 percent of the time, the referring 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 reporting step added time and reduced accuracy. Physicians were resigned to the systems failings. Thats just the way things worked, Forbes says. Its kind of like typewriters. People say, How did you ever use typewriters? But when thats all you had,
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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. Everything is here patient history, the procedures, pressures, pictures everything is templated, says Forbes, clicking through a cath study in a room lined with computer 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 Childrens Hospital of Michigans cath lab, had reservations about the point-and-click system. I wasnt 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. Its as close to real-time reporting as you can get. Im spending less time doing all the chores we used to
have, so theres more time to do other things.
The Ripple Benets

In Milwaukee, the echo lab completed a study comparing the last month of transcription-based reporting to the syngo Dynamics-templated system. Our median time went from 24 hours to about an hourand-a-half, Peter Frommelt says. We dont have to do anything but click a button. Weve 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 physician satisfaction improve, but from a safety standpoint, I think its a real advance. Doctors are spending less time generating 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 minutes 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 pictures just for a normal study. Increasing throughput was a bonus that physicians at Childrens Hospital of Wisconsin did not expect. The echo lab director 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 physicians 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 its all done electronically. Efficiencies created by syngo Dynamics have freed up staff for other tasks. At Childrens Hospital of Michigan, one staff member used to spend 90 percent of
Childrens Hospital of Michigan, part of the Detroit Medical Center, is the only freestanding childrens hospital in Michigan and the states leading training center for pediatricians. On the left: Paul Webster (top), Dr. Thomas Forbes
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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
Summary
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 workflow 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
Increasing throughput was a bonus that physicians did not expect.
Efficiencies created by syngo Dynamics have freed up staff for other important tasks.
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 Childrens Hospital of Wisconsin have noted improved consistency in reporting. Each physician had his own style for describing a heart lesion in dictation. With the templates, because everything is structured, everyone is reporting things in a more uniform way, says Peter Frommelt. Theres no question that for the referring physician, its 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 procedures that we always do, and we may sometimes forget to dictate them. Sometimes 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
[virtual private network] connections with no loss of quality, and have our cardiologists 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. Childrens 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? Im ecstatic! says Lead Cath Lab Technologist Paul Webster, RT (R). The Siemens collaboration has been seamless, Turner says, Theres a lot more we can do with it. It grows with you. Its really only limited by the user. What is happening at Childrens Hospital of Wisconsin and Childrens Hospital of Michigan is so revolutionary that Peter Frommelt believes it will rewrite pediatric imaging standards. I dont think there is anyone out there who can tell you how long it should take for a finalized echocardiogram report to be available in an electronic medical report to the referring doctor, he says. But what weve found is that it shouldnt be days it can be hours.
*Results may vary. Data on file.
Ron French is an award-winning reporter for the Detroit News.
Further Information
www.siemens.com/syngo-suite
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Image Management
How happy am I with the system? Im ecstatic! says Lead Cath Lab Tech Paul Webster, RT (R). The Siemens collaboration has been seamless.
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MRI in Oncology
Speeding up Clinical Workow in Cancer Staging

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 Bhm
Suspected rectal cancer reads the referring diagnosis from the family physician which the patient brings to the Comprehensive 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 highresolution magnetic resonance imaging (MRI) currently the best imaging procedure 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 ArndOliver Schfer, 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 Professor 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 abdomen and maybe a sonogram. And then, during another appointment, a CT scan of the thorax is performed, explains Professor Langer as he describes the usual procedure. If youre lucky, the examinations are performed three days in a row; if youre not, it can take three weeks!
Accurate Therapy Planning

In Freiburg, MRI is performed after rectoscopy and biopsy, where a sample is taken for the histological examination. We can perform part of the tumor characterization using MRI, says Langer. The various image impressions that can be obtained in magnetic resonance imaging by using
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 provides us with much more information. The patients images and diagnostic findings are subsequently discussed at the interdisciplinary tumor conference. Normally, 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 aftercare. MRI is an excellent way to gain an indication of recurrence or metastases, often at a time when the patient subjectively 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 Schfer. Through semiannual examinations, 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
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Movement is what it is all about: Dr. Schfer 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
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
Summary
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 information (primary tumor evaluation, localization of metastases, and detailed anatomy) available after only one MRI exam
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 clinical colleagues there is always the risk of a loss of information, says Professor Langer. Here, the oncologist, gastroenterologist, 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 timeconsuming 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 Freiburg has solved this problem with a revolutionary 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
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MRI in Oncology
improves patient comfort while delivering 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 quality in MRI suffers from movement. However, since several coils can be activated simultaneously with Tim, fast measurements across a broad area are possible due to parallel imaging. This Multislice Acquisition is a critical requirement in order to perform measurements with continuous table movement. The systems software reconstructs images in a way that eliminates motion artifacts 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 Schfer, ensures that images are acquired at the magnets isocenter. For that reason alone, the measurement quality is excellent.
cinoma, the most convincing application field of syngo TimCT technology in oncology. Naturally, MRI can be used to localize tumors and metastases of other types of cancer. These include breast and bronchial, prostate and pancreatic cancers, as well as the display of skeletal tumors and lymphoma.
Not an indication today for which it cant 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 Crohns Disease. Using contrast agents, inflammations of the intestinal wall are displayed well in MRI. The characteristics of the inflammation, involvement of the surrounding tissue, and complications such as fistulas, abscesses, and stenoses, 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 persons entire muscular system and localize inflammations. There is not an indication today for which it cant be used. In three years, we may well be performing the entire spectrum with a moving table, where today the examination is stationary, adds Dr. Schfer. He has great hopes for diffusion-weighted imaging: This enables better characterization of tumors, and will simplify their differentiation. 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!
A Dream Comes True

Professor Langer is proud that his team in Radiology together with the Department of Medical Physics under Professor Jrgen 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 examinations with MRI since the early 90s we were both convinced it had to be possible somehow. The rapid development of computed technology provided the critical prerequisite. It gave us fast computers 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 examinations have been performed in Freiburg with the new technology. About 1,500 of these examinations were for rectal car-
The entire patient is examined seamlessly, and all in about six minutes.
Arnd-Oliver Schfer, MD, Department of Diagnostic Radiology, University Hospital Freiburg, Germany
After completing her biology and chemistry studies in Heidelberg, Sonja Bhm worked for many years as a medical editor. She has worked as a freelancer since 1997 and regularly contributes to numerous health and medical media, and edits professional journals.
Further Information
www.siemens.com/ MAGNETOM-Special-2006
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Therapy Control
Cancer Monitoring: Find Fight Follow

Imaging is becoming a popular instrument across all areas of disease management from initial diagnostic 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
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Summary
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 PETCT) 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
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 developed two valuable software packages for monitoring cancer. syngo CT Oncology includes set algorithms for the segmentation of lesions in the liver, lungs, lymph nodes, and other regions of the body in computed tomography (CT) images. The software calculates various tumor parameters and compares them with subsequent diagnostic findings. As a result, tumor burden, growth parameters, and
other values can be tracked. syngo TrueD was developed for hybrid imaging using positron emission tomographycomputed tomography (PETCT) or single photon emission computed tomographycomputed tomography (SPECTCT). As a result, data sets from PETCT examinations acquired at two or three time points are automatically registered for an onscreen comparison. Leading cancer centers are working with these two software tools.
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The new syngo CT Oncology software 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
Let the Computer Do It: Fully Automated Tumor Tracking

Before data becomes information, it must be thoroughly examined and analyzed. As computed tomography (CT) scanners produce a growing torrent of data, radiologists confront a data-or-information question every day: how to obtain the maximum patient benefit from the hundreds of slices that an advanced CT scanner produces 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 workflow 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 measurement, routinely calculate tumor volume, and support a wide range of the datahandling operations necessary for topflight 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. Its very quick, accurate and consistent in measuring lesions using the RECIST [Response Evaluation Criteria in Solid Tumors] and WHO [World Health Organization] 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 manual and automatic segmentation and measurement of abdominal and pelvic lymph nodes corresponded closely, according to both RECIST and WHO criteria. Similarly, he reported to the Society of Gastrointes-
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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 measurements those repetitive functions are now all embedded in the software. When you follow patients based on these measurements, 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, consistency 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 difficult to measure.
Better Patient Care

On the practical level, automated measurement 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 relative 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 radiology, 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-
tinal Radiologists that the software successfully segmented and measured 22 liver lesions on contrast-enhanced CT scans from 12 patients.
Simplied Follow-ups
Another key advantage of syngo CT Oncology 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 doctors hands, but rather allows the physician to use preferred measurement standards. The software can segment out the tumor and correctly measure it, providing 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 measurements, says Yaghmai. Its a much faster way of comparing and analyzing data. On follow-up scans, the system displays 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-consuming process, says Yaghmai. An automated 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 simplified follow-up is one of the most significant benefits of this new syngo software;
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ber of CT scans obtained in large centers like ours is increasing.
Volume as a Standard Modality?

Fast, accurate, and repeatable tumor segmentation and measurement are significant advances, but syngos 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 volume 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 component of a CT scan is a two-dimensional slice of the patients 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 measure 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 important role in follow-up. Here, too, automated measurement may provide an improvement in accuracy. Although the exact implications of volume 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 measurements, he says. Its 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.
Left: Professor Bernd Joachim Krause, MD Right: Andreas Wahl, MD
Master of Comparison in Hybrid Imaging

In PETCT (positron emission tomographycomputed tomography), metabolic images are superimposed on anatomical images. Using this hybrid-imaging method, tumors are no longer detected merely by appearance, but through their metabolism as well. Using the syngo TrueD software package, hybrid images acquired over a period of time can be compared and quantified on a display for the first time. Medical Solutions spoke with Professor Bernd Joachim Krause, MD, of the University Hospital Rechts der Isar in Munich, and Andreas Wahl, MD, of the PETCT Center in Hamburg, Germany, regarding its clinical potential. 74 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 comparison 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 relationship 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 evaluating 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 comparisons are improved with using a software with specialized tools like syngo TrueD. And this is possible irrespective of whether standardized criteria such as
metabolic activity calculated as Standardized Uptake Value (SUV) longimetry according to WHO [World Health Organization]/RECIST [Response Evaluation Criteria in Solid Tumors] standards or measurements 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. Additionally, 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
This is the reason why PETCT 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
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also of significant benefit, because comparison of the present PETCT with these former (external) examinations is necessary 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 regarding their effect. Morphology alone is no longer sufficient. This is the reason why PETCT is so important in oncology, because we learn something about both function and structure. For therapy control, we therefore have a great need for new criteria that allow assessment of therapy response so-called surrogate parameters. To date, the primary orientation 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 treatment. The task before us is very clear: We have to find reliable thresholds for
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, PETCT-Center, Hamburg, Germany
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 values 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 established and can be used predominantly for solid, well-definable lesions with a minimum size.Those criteria are based on two-dimensional [WHO] or one-dimensional [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 calculation of tumor volume by means of multislice 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. Hodgkins, 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 different surrogate parameters for various tumor entities in the future. Volume will
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Individualized therapies are a main goal in the future.

Professor Bernd Joachim Krause, MD, Senior Physician, Technical University, Hospital Rechts der Isar, Munich, Germany
merely be one of many. In addition to maximum length and volume, other conceivable 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 volumetric variables (among others, segmentation-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 PETCT fall under private physician or individualized healthcare services, the only exceptions being staging, restaging, and follow-up for non-small cell lung cancer.
Their in-patient use is still difficult due to financial restrictions. What do you think about this situation? WAHL: Approval of FDG-[18F-fluorodeoxyglucose-]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 indication make prognoses for the approval of further indications difficult. However, with new modes of care in public health insurance, 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 general cost reimbursement. Fortunately, a change has been made in cost reimbursement 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
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.
David Tenenbaum is a freelance science, medical, 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 newspapers and scientific journals.
Further Information
www.siemens.com/ct-oncology www.siemens.com/TrueD
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Radiology Workow
Jameson Health System provides care to citizens of New Castle in Western Pennsylvania.
Enhancing Radiology Workflow

In 2004, Jameson Health System in New Castle was the 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 challenging, because she would be redefining the way the department operated. And she was right: The entire department redesigned its workflow, and Beight educated the staff members about their new roles. Despite the challenge of organizing work spaces, designing workflow, and installing 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 recently, there were many physicians who
syngo Suite quickly became Dr. Cooks favorite RIS system because of the concise way it displays information and its voice recognition system which he considers to be the best.
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had never used a PACS to view images. The majority of them still relied on film to evaluate each case, and paper to document their findings. Computer education and workflow design were required for all physicians. Within a week of being introduced 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
companies, services, and packages available. 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 compact and very logical, and its 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
From image acquisition to image display, diagnosis, and voice recognition for reporting, syngo Suite supports the radiologic process.
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 clinicians. Making the transition to the syngo Suite system has been made easier because of its familiar Siemens design. Many radiologists 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
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 recognition 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-
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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 digital scanner that enables them to have all information electronically. This complementary 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 decreases the likelihood of a typing error.
Turnaround Time Cut in Half

Both Beight and Cook applaud the benefits of a more efficient workplace with syngo. Turnaround time was about 24 hours before syngo Suite was implemented,
the risk of misplacing patient studies, which required extra effort to retrieve. With syngo Imaging, we find less studies being misplaced. With the results immediately 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
The server and IT backbone work in the background, unnoticed by the user.
starting from the time the patient completed a test to the time the radiologist signed off on the final report. Since syngo Suite has been implemented, the turnaround has been cut in half to approximately 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 dont 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 dont 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
copy pieces of film and the chemistries and maintenance for the developing process, 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 radiologists efficient because they are provided with an easily sorted task list, and their time and energy is spent interpreting images. Dr. Cook echoes Beights 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.
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Single sign-on across syngo Suite
syngo Portal Radiologist displays scheduled procedures each day.
Common syngo user interface
Radiology Workow
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 interpreted. 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.
Redening Workow
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 locations at once significantly improves workflow efficiency. Such organization has also improved how consultations are performed. With syngo Suite, the referring physicians can access the digital images directly from their practice. 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 reviewers 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 Internet that they are accustomed to at their office workstation. The implementation of syngo Suite has truly redefined the entire workflow structure 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, weve been very satisfied. 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.
Summary
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 transcriptionists 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
Robert L. Bard is a freelance medical writer certified by the American Medical Writers Association who also conducts clinical research at the University of Michigans Division of Cardiovascular Medicine.
Further Information
www.siemens.com/syngo-suite
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Facility Planning
Stepping Outside the Bounds

Susquehanna Healths Cancer Center breaks the boundaries of its physical location to capture ambient daylight, improve the patient experience, and, ultimately, offer the kind of workow efciency that promotes operational and personal well-being.
By Karen Schweizer
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.
Nestled between a branch of the Susquehanna 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 Center, Divine Providence Hospital, and Muncy Valley Hospital. It is ranked as one of the nations 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, PhysicianFocused
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 regarding workflow, says Karen Armstrong, Senior Vice President and Chief Information Officer (CIO), Susquehanna Health. We wanted the facility to be patientcentered 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 companys Global Solutions Divisions 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 recommendations, continues Armstrong. We believed the Siemens consultants could really take the project to the next level. Collin Beers, Senior Vice President at Granary Associates, agrees that the Siemens consultants brought value to the project.
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Summary
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 phlebotomy 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 infusion rooms, less exam rooms, plus shell space for easier and cost-efficient installation of a future linear accelerator
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 dialogue took on a whole different angle.
tivity and efficiency are important elements in the design, we also needed to weigh that against what was best for the patient.
Experienced in Workow Design

In fact, key adjacencies were important elements of the consultants recommendations. 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 recommended positioning the pharmacy between medical oncology and the chemotherapy infusion area to reduce the distance nurses 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. Its 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.
Improved Efciency and Outlook

The medical oncology and radiation oncology service areas currently reside in an 11,000-square-foot space in the basement 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 Centers key stakeholders to review potential options and balance the Centers 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 overlooking 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 staffs 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 staffs produc-
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 operations, 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
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Facility Planning
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Facility Planning
We know the Siemens consultants will help us achieve good, efcient outcomes.
Karen Armstrong, Senior Vice President, CIO, Susquehanna Health, Williamsport, PA, USA
Further Information
www.siemens.com/ medical-consulting
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 potential volume evaluation resulted in an increase 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. Planning 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. Weve worked with other strategic 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 wasnt just a recreation of the way Susquehanna had worked before. Our experience is limited by what we know to be true here; it doesnt necessarily help us forecast for the future, says Armstrong. Thats 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 Schweizers 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.
Optimizing Assets and Identifying Opportunities to Increase Revenue

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 Susquehannas imaging technology deployment based on demographics, services, resources, utilization, and efficient patient processes. In particular, 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 relocating 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 imaging technology. They confirmed some facts about the productivity of our computed 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 recommendations, 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 Susquehannas 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 weekends (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 departments 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.
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Facility Planning
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Virus Protection
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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 hospitals patient care and efcient therapy for complex cardiac, vascular, and metabolic diseases.
By Christian Bernhart
Virus Protection to Safeguard Both Patient Care and Systems

Early in the morning just before seven, the first outpatients arrive at the University Hospital Basel, Switzerland, for radiological examinations. People who work during the day appreciate the early morning and after-hour appointments. Just past the main entrance at the address of Petersgraben 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. 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 hospitals clinics and referring physicians, 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 examine arterial vessels. In addition, therapy is performed on cardiac, renal, and brain blood vessels. In the two standard radiography rooms, the first patient examinations began at 7:00 a.m. By midday, up to 120 radiographic diagnoses are already available.
350 Patients per Day

The radiological technician (RT) has already booted up the first magnetic resonance imaging (MRI) and computed tomography (CT) workstations. The days schedule for the normal flow of radiolo-
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Virus Protection
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
The Siemens imaging systems in radiology deliver 10,000 fully digitized patient images per day at a volume of 18 gigabytes, which are processed at five workstations 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 todays number 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 Steinbrich. 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 purchasing it. He reasoned that his computer, connected to the Internet and the hospitals administrative network, always operates 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 examinations and therapy, it is not just a question 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 interruption. This is enabled on the one hand by welltrained experts. A full-time RT is responsible for the smooth flow of examinations from 7:00 a.m. to 7:00 p.m. Inpatients fill the time between outpatient appointments, 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 multifunctional image-controlled intervention room (MII). The room is equipped with CT and MRI systems, and is operational around the clock. Siemens Virus Protection ensures longterm, 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 conventional 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 product-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 improperly configured commercial scanners. As part of their continuous monitoring
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Virus Protection
With its Virus Protection, Siemens has set a new standard.

Christian Kluth, Director of Medical and Operational Technology, University Hospital Basel, Switzerland
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Virus Protection
of information, these units automatically react to a virus by immediately stopping the data flow.
Tested for Operational Safety and Reliability
Summary
Challenge: Danger of a virus, trojan horse, or worm infection in a hospital IT network System shutdown during complicated, computer-supported treatments Security of image and patient data jeopardized
Solution: Virus scanner installation of the thoroughly tested virus scanner 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 validation on a product-specific basis of hotfixes released by Microsoft
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 protection? The workstations used by physicians, 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.
cating a virus, states Kluth. But how high does he classify the risk of a medical system infection, given the fact that the information flow of the systems connected to the radiology information system (RIS) network is separate from the administrative network of the University Hospital Basel? Kluth notes a recent example just before the installation of Siemens Virus Protection, where the speed of data traffic for an imaging system dropped significantly. The hospitals internal IT department determined that this system had released a virus that flooded the network with useless data. The experience showed Kluth that one can never assume a clean network. Such an assumption would be as incorrect as someone going on the Internet 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 guarantee a clean network. With its Virus Protection, Siemens has set a new standard, 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 interfaces between the individual networks, and therefore the risks. Other possible sources of infection include data transfers from memory sticks or connected laptops. For Franz Buffon, the Head of IT at the University Hospital, this represents a particular challenge to the university because researchers and professors worldwide visiting for conventions and symposia can enter data into the hospital network 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
Automatic Feedback
Siemens Virus Protection at University Hospital Basel is not only active during the installation of new virus patterns. All systems 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 angiography 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 patterns reach the individual systems directly via the specific Internet Protocol (IP), saving 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 fortunately not received any messages indi-
Result: Secure workflows throughout the Radiology Department Protected patient and image data Immediate help for problems that occur on short notice
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The Siemens imaging systems in radiology deliver 10,000 fully digitized patient images per day. According to the Head of Radiology at the University Hospital Basel, Professor Wolfgang Steinbrich, it would be a disaster if one system were down.
has to be authenticated via a user name, password, and perhaps soon via fingerprint, before logging on.
Trust as a Prerequisite
The RTs in Radiology on the lower floor of the hospital rarely look at such considerations during their busy day. By now, it is midday. The radiological technician responsible for scheduling takes a short break, although the work within the department continues. Looking at an on-screen monitoring system, she sees that the department 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 infection 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 correct 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
implement this innovative and proactive solution.
Christian Bernhart works as a scientific journalist in the areas of medicine and technology. He is also editor for University Hospital Berns visceral medicine topics, and writes for well-known daily and weekly newspapers, as well as German magazines like Bild der Wissenschaft.
Further Information
www.siemens.com/ virus-protection
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C-arm in Gastroenterology
The multitalented ARCADIS Avantic examines more than just hearts and kidneys. The mobile 33-centimeter image intensier opens up innovative opportunities for gastroenterologists. Journalist Martina Lenzen-Schulte interviewed Matthias Maier, MD, Head of the Department for Internal Medicine at the Knappschaft Hospital Pttlingen, Germany, to discuss the new C-arm.
Better Abdominal Images
Dr. Maier, you tested the new C-arm, ARCADIS Avantic, in your gastroenterological 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 gastroenterology has to meet. What characteristics of the new system impressed you most? MAIER: First of all, the performanceoriented image intensifier. Combined with
the generous image segment available for review, it provides excellent image impressions, not only qualitatively but also with respect to dimensions. This is of special advantage in endoscopic retrograde cholangiopancreatography (ERCP). Can you explain this in greater detail? MAIER: ERCP is one of the most frequent interventional procedures in gastroenterology 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
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C-arm in Gastroenterology
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 gallstones 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
in particular to patients who suffer from gallstones and frequently makes evaluations under fluoroscopy rather difficult unless you have a system that has that much power. Even very thin wires of the instruments which were previously difficult 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.
helpful in determining if the walls are smooth or in seeing the smallest irregularities that have to be considered. I consider 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
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 Pttlingen, Germany
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 frequently with adipose patients. This applies
This means that you have improved documentation because the images show the details. MAIER: Correct. And it is not just advantageous 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 separated from other diseases and blockages of the biliary tract. Exact imaging is extremely
open. Such constrictions may have been caused, for example, by malignant growths. I expect that this procedure will become more frequent due to consistently improving 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 disorders. How did you experience the handling of ARCADIS Avantic?
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The transportable ARCADIS Avantic allows for flexible application in the hospital.
Summary
Challenge: View all anatomical structures of interest during an gastroenterological intervention simultaneously Adipose patients and thinner wires make detection more difficult Solution: 33-centimeter image intensifier Improved spatial resolution Result: Optimized navigation with a performance-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
MAIER: Its a highly sophisticated device and not in the least cumbersome for such a large system. You dont need physical strength to operate it. In addition and we consider this to be highly advantageous 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 advantage 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 pancreas, 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 decisionmaker, of the department? MAIER: Id 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, its highly advantageous 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. Id like to repeat what I said in the beginning: The system should be introduced more often to potential users at exhibitions.
Martina Lenzen-Schulte, MD, is a physician, author, and medical journalist. She is a frequent contributor to medical magazines and the scientific pages of German-speaking public media.
Further Information
www.siemens.com/ Arcadis-Avantic
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Further Reading
Ysio wi-D is the latest digital radiography solution that combines two different detector designs for optimal workflow enhancement.
Fluorescence-guided Surgery
In todays surgical environment, the need for minimally invasive procedures and cutting-edge technology 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 clinical 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 invested in VisEn Medical, Inc., a company that is developing 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.
Not Just the Regular Mobile Detector

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 positioning 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 radiographic 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 modification. With the latest generation of detectors, Ysio wi-D will be primed for future technological applications.
* 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.
www.siemens.com/ AXIOM-RSNA-2007-wi-D
www.siemens.com/ Solutions-RSNA-2007-Fluorescence
Large Volume syngo DynaCT could enhance imaging possibilities in todays interventional radiology.
Large Volume syngo DynaCT

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
height of 18.7 centimeters can be covered. This extended field of view is especially important to treat liver tumors via chemoembolization, 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 orientation 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 extended field of view allows coverage of the whole thoracic spine. It is very helpful when performing spinal procedures such as vertebroplasties, kyphoplasties, lumbar punctures, and myelographies. The portrait mode is also a valuable application for carotid stenting. The results of the stenting procedure can be verified immediately after placing the stent. The cerebral vessels as well as the carotid artery can be seen in one image.
www.siemens.com/ AXIOM-RSNA-2007-DynaCT
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Wheres Parkers lab report?
Wheres Parkers X ray?
Wheres Parker, anyway?
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Feedback
Dear Reader,
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 subscriber 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 subjects of the magazine. Topics we would like to cover include workflow, knowledgedriven medicine and healthcare IT, molecular medicine and in vitro diagnostics. Other features will be trends in healthcare, 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 to the editor should be addressed to:
by mail: Siemens AG, Medical Solutions CC CB1 Doris Pischitz Chief Editor Medical Solutions 91050 Erlangen Germany by e-mail: editor.medicalsolutions.med@ siemens.com by 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.
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 feedback and, in so doing, allow your fellow readers to partake in your experiences and reactions to our topics. We are looking forward to hearing from you! Sincerely,
Doris Pischitz Chief Editor
Trade Fairs & Congresses

Title Moscow Healthcare EuroEcho Arab Health 2008 HIMSS 2008 Location Moscow, Russia Short Description International Exhibition of Health Care, Medical Engineering and Pharmaceutics Date Dec. 5 9, 2007 Contact www.zdravo-expo.ru/en
Lisbon, Portugal Dubai, United Arab Emirates Orlando, FL, USA
Annual Conference of the European Dec. 5 8, 2007 Society of Echocardiography International Healthcare Exhibition and Congress Annual Conference and Exhibition of the Healthcare Information and Management Systems Society Annual Meeting of the European Society of Radiology Annual Scientific Session of the American College of Cardiology Annual Meeting of the Japan Radiological Society Information Technology in Healthcare Annual Congress of Chief and Senior Executives from all Sectors of Healthcare Jan. 28 31, 2008 Feb. 24 28, 2008
www.euroecho.org www.arabhealthonline.com www.himssconference.org
ECR 2008 ACC 2008 JRS 2008 ITeG World Health Care Congress
Vienna, Austria Chicago, IL, USA Yokohama, Japan Berlin, Germany Washington, DC, USA
Mar. 7 11, 2008 Mar. 29 Apr. 1, 2008 Apr. 4 6, 2008 Apr. 8 10, 2008 Apr. 21 23, 2008
www.ecr.org www.acc.org www.j-rc.org www.iteg.de www.worldcongress.com
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Imprint
2007 by Siemens AG, Berlin and Munich, All Rights Reserved Publisher: Siemens AG Medical Solutions Henkestrasse 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 Stcker, Abigail Weldon Editorial Assistance: evolo marketing gmbh Production: Norbert Moser All at: Henkestrasse 127, D-91052 Erlangen, Germany Phone: +49-9131-84-7529, Fax: +49-9131-84-4411 email: editor.medicalsolutions.med@siemens.com Design and Editorial Consulting: independent Medien-Design, Mnchen, Germany in cooperation with Primafila AG, Zrich, Switzerland Art Direction: Horst Moser Layout: Lucie Schmid Editorial Coordination: Christa Lberbauer All at: Widenmayerstrasse 16, D-80538 Mnchen, Germany PrePress: MEDia_asset_pool Waldstrasse 18, D-91054 Erlangen, Germany Printer: Farbendruck Hofmann, Gewerbestrasse 5, D-90579 Langenzenn, Germany
Photo Credits: Cover: Andreas H. Bitesnich Cover Story: Andreas H. Bitesnich et al. Breast Cancer: Imke Lass, Steffen Thalemann, et al. Electronic Health Record: Jrgen Hinterleithner Market Niches in MRI: Primin Rsli Remote Solutions: Marion Stephan, Jrgen Hildebrandt Digitized Hospital: Lars Hinsenhofen Image Management: Fabrizio Constantini MRI in Oncology: Primin Rsli Therapy Control: Marion Stephan, Imke Lass Radiology Workflow: Jez Coulson Facility Planning: Barry G. Holmes Virus Protection: Karl-Heinz Hug, Urs Flury C-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 authors 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
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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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*Not available for sale in the USA.

*Not available for sale in the USA.

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