IRQ Articles

EMERGING TECH: APPlied innovation 

01-18-2018 12:51

How IRs are transforming medicine through app creation

By Melanie Padgett Powers  Winter 2018

Hands using mobile devices

An app to enhance collaboration

Picture a group of IRs gathered for rounds each day, updating one another on cases, discussing and debating potential treatments. Through this peer review, the IRs offer valuable and interesting options and insights—just as they do, perhaps, in your setting.

At Beth Israel Deaconess Medical Center in Boston, however, IR rounds are completely different, thanks to the development of the IR Peer Review app created for and by interventional radiologists at the hospital.

“The main problem was that we were generating a lot of rich peer-review data in our academic practice every time we reviewed cases the day after they were performed—but we weren’t capturing this data,” says Seth Berkowitz, MD, director of radiology informatics innovation at Beth Israel Deaconess Medical Center and the app’s developer. “A lot of lessons that were learned were easily forgotten because we had no formal process for recording them.”

Of course, the requisite peer-review system existed, but the team’s data showed IRs weren’t systematically reviewing IR cases. “They were reviewing generally noninterventional procedures. We needed a different way of collecting data than the traditional diagnostic radiology peer-review system,” Dr. Berkowitz says.

As the doctors began to brainstorm, two goals emerged: to create a peer-review app specific to interventional radiology—not adapted from diagnostic radiology—and to develop a more effective, user-friendly system that met all peer-review requirements, says Salomao Faintuch, MD, clinical director of interventional radiology at Beth Israel Deaconess and assistant professor of radiology at Harvard Medical School.

Now, during rounds at Beth Israel Deaconess, one of the IR attendings volunteers to record the data on the app. As the cases are discussed, the interventional radiologists come to a group consensus, pooling everyone’s knowledge, rather than relying on one physician to review the case. One of the problems with individual peer review, Dr. Berkowitz says, is “there’s an inherent bias in that there can be an assumption that the doctor doing the review is correct if there is a discrepancy, which may or may not be the case.”

The names of the attendings present are added to the consensus documented in the app, ensuring they all receive credit for that part of the peer-review process. Another benefit is that the operator on the case is usually in attendance, unlike with paper peer-review, and can answer questions from the group, says Olga R. Brook, MD, clinical director of CT at Beth Israel Deaconess and assistant professor of radiology at Harvard Medical School.

The app has led the IRs to discover issues that need to be addressed. “A category we call ‘learning opportunities’ allows us to capture key points; in the process, some trends have become apparent,” Dr. Berkowitz says.

For example, physicians can get into a rhythm of giving every patient the same type of antibiotic before a procedure, he says. But through the new peer-review system, they discovered a series of patients who had developed severe sepsis after their routine procedure despite antibiotic prophylaxis, so they created a better process to flag these patients.

“It wasn’t apparent there was a pattern until we looked at the peer-review data,” Dr. Berkowitz says.

The hospital’s IRs have been using the app for two years. They aim to expand the data review process and to faster translate the learning opportunities they discover into actual changes, Dr. Berkowitz says.

Dr. Berkowitz has created two other apps. An iOS-only app allows IRs to view scans on their phones. Even though the images are small, the app has allowed them to quickly access data, which can be helpful especially when they’re on call at home in the middle of the night. The app takes advantage of capabilities not available on most laptops, requiring use of the fingerprint reader to access the data. And if the app is used on a tablet, users can draw on the images, which can be helpful when explaining procedures to patients.

An unexpected outcome is that IRs use the app to “check in” on one another, browsing for interesting cases that might have come up on their days off. “It’s very collegial,” Dr. Berkowitz says. “People will look at images and say, ‘that was a great case you did.’ I don’t think you would have that without the app.”

Dr. Berkowitz also recently developed the Photoconsult app, which allows any Beth Israel Deaconess physician to take photos and send them directly to the electronic health record. It can be helpful for junior residents to take photos of a suspected port infection, for example, that they want to ask senior residents or attendings about. Unlike with a regular camera on a smartphone, the app meets all security and privacy requirements.

An app to aid in diagnosis and education

A Stanford interventional radiologist has developed a mobile app to address an unmet medical need that affects thousands of patients a year. When William T. Kuo, MD, learned about the increasing number of complications from inferior vena cava (IVC) filters, he wanted to help clinicians properly diagnose and treat their patients. Dr. Kuo is professor of interventional radiology at Stanford University Medical Center and director of the Stanford IVC Filter Clinic.

The challenge, said Dr. Kuo, was to help IRs manage complications related to IVC filters. “A major complicating issue is that a myriad of IVC filter types now exists, which can lead to confusion when these devices are encountered on X-rays,” Dr. Kuo says. “The IVC Filter Compendium is a powerful mobile application that allows rapid identification of all IVC filter types that may be encountered on routine imaging. This allows physicians to properly diagnose filter-related complications and problems associated with specific filter types that may otherwise go unnoticed on routine X-rays.”

Dr. Kuo and Stanford IR fellow Steve Deso, MD, successfully obtained a grant that allowed them to hire a programmer and secure other resources. They also enlisted the help of two other Stanford radiology trainees, Michael Muelly, MD, and Ibrahim Idakoji, MD, to create the app. The team gathered safety data from the U.S. Food and Drug Administration (FDA) MAUDE database and peer-reviewed studies on the various IVC filters. They acquired high-resolution images of each device and paired the images with matching CT and fluoroscopic images from an IRB-approved registry database. The app, which was licensed through Stanford University, is available to any IR for both Android and iOS platforms.

“Although the mobile app was originally intended to serve as a portable tool for patient care, we discovered it could also serve as a valuable educational tool for all medical trainees, clinicians and patients who wish to learn more about vena cava filters,” Dr. Kuo says.

An app to improve cancer treatment

Doctor pushing buttons on HUDAnother IR-specific app aims to help physicians treating liver cancer. David Liu, MD, a physician with Vancouver Imaging and a clinical professor in the radiology department at the University of British Columbia in Vancouver, created the DAVYR app to better calculate the compartmental activity and dose of the radiation during Trans Arterial Radioembolization (TARE) in order to optimize the amount of radiation to the tumor and minimize exposure to nontargeted areas of the liver and the rest of the body. (DAVYR stands for “dosimetry and activity visualizer for yttrium-90 radioembolization.”)

The app can be used with either of the two commercial radioembolization products on the market. “The DAVYR app is meant to democratize the discussion on dose and activity so you don’t have to rely on the product brochure to tell you what to use,” Dr. Liu says. “The purpose of the app is to encourage IRs to understand the physics and biology of therapy, rather than having a cookie-cutter approach to TARE.”

The app uses all of the current calculation methods (MIRD, BSA and partition) available with both products. IRs can change the variables, which the app will instantly recalculate, allowing IRs to compare and contrast doses in real time. In addition, iPad users gain access to a host of graphical outputs.

“It literally can not only save hours of time of work, but it also allows you to have a more agnostic approach to the concept of dose and activity, which are critical in radioembolization,” Dr. Liu says.

Interventional radiologists are known for embracing new technologies, so app development is a logical next step as IRs advance the field and improve patient care. “Relying on companies to provide resources such as apps and clinical tools is helpful, but in order to get above the fray, we have to go back to our heritage as makers and innovators and create new lines of thinking and new solutions to old problems,” Dr. Liu says.

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Publicly available apps

IVC filter app logoIVC Filter Compendium | iOS, Android | free

DAVYR app logoDAVYR | iOS | free

6 tips before you build an app

Have a great idea for an IR app? IRs who have been through the app development process offer several tips:

  1. 1. Identify an unmet need. What problem will your app help solve that is not already available to IRs?
  2. 2. Have a clear vision. You need to be prepared to sell your idea. You may need to seek approval from your institution, which may also provide financial support. If your institution gives you the go-ahead but doesn’t provide funding, you need to be prepared to convince others to fund your project. Grants could cover the costs of hiring an app developer (if you don’t do this yourself) and a graphic designer.
  3. 3. Picture your concept in a visual form. David Liu, MD, clinical associate professor in the radiology department at the University of British Columbia in Vancouver, worked with an IOS programmer and graphic designer to synthesize his idea of calculating radioembolization doses into a visual, user-friendly app. Storyboarding his idea was helpful.
  4. 4. Be aware of federal requirements regarding medical device regulations.
  5. 5. Test, test, test. Dr. Liu asked radioembolization experts around the world to try out his app prototype. He ended up beta testing about 36 versions of the iOS app before it became available. “Halfway through it felt like I was kind of walking through the dark; we were in an endless loop of beta testing,” Dr. Liu says. “Ultimately, I think that really made the product better because the peer-review process through beta testing is dynamic and almost instantaneous.”
  6. 6. Be willing to adapt. Even after the app was released, Dr. Liu discovered challenges: The app was originally developed for iPads, but many IRs said they didn’t have ready access to iPads. In response, Dr. Liu developed a 2.0 version that is also compatible with the iPhone. The app is not currently available for Android devices; Dr. Liu is considering that option, but it will depend on funding.

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