Today, equine veterinarians can diagnose and treat disease with more speed and certainty than ever thanks to an array of increasingly sophisticated technologies. The digitization of clinical information has had a profound impact on the quality of veterinary care and how veterinarians consult with one another and communicate information to clients.
Diagnostic imaging has evolved rapidly in the last five years. "The biggest change is the diversity of things we can look at," says Anthony Pease, DVM, MS, Dipl. ACVR, section chief of diagnostic imaging at Michigan State University's College of Veterinary Medicine. "Everything that we do now is computerized, whether it's ultrasound, nuclear medicine, MRI, or CT."
Computed Tomography (CT) Computed tomography uses radiographs (X rays) and image processing software to generate three-dimensional images of body structures. "CT allows us to really evaluate bone, because it is still X ray technology," says Pease. Unlike a radiograph, which provides a two-dimensional image, CT displays structures in three dimensions by taking pictures in "slices."
"CT is very good for visualizing head trauma, dental disease, and nasal problems, which are common in horses," according to Pease. "The structures of the head are difficult to see in two dimensions because there is so much superimposition (anatomical structures located above and beneath each other)."
Magnetic Resonance Imaging (MRI) Magnetic resonance refers to the movement of water molecules in the body (much of the body is water) when they are pulled by an electromagnetic field. An MRI machine consists of a radio frequency transmitter, a magnet, a computer to process images, and a computer monitor on which to view the images. A radio frequency is applied to the magnetic field, which temporarily pushes hydrogen atoms in one direction. When the molecules revert back to their original position, a special antenna (called a coil) detects and records the "spin" of the hydrogen atoms (resonance). Software transforms the resonance data into a digital image that is saved on disk or displayed on a computer screen. Different MRI pictures (called sequences) can be captured to help veterinarians fine-tune their view of anatomical structures; these sequences provide exquisite detail of water and soft tissue.
"MRI has made the most impact on diagnosing problems in the hoof and lower leg," says Pease. "Whenever you have disease or trauma, edema (fluid swelling) is one of the first things that happens. Water is detected as a bright area on an MRI. We can see the soft tissue damage where there might not necessarily be a bone lesion. This helps us diagnose navicular disease and suspensory ligament tears.
"More importantly," adds Pease, "we can diagnose the progression and regression of the disease, which can help in determining the best time to start working the horse again."
Scintigraphy With scintigraphy the veterinarian injects a specialized agent into the horse that has small amounts of radioactive material. This agent selectively binds to or is eliminated from specific structures. A special gamma camera detects gamma radiation emissions from the radioactive material and records the images on a computer display or film. Scintigraphy not only helps reveal disease processes but also shows functional information that cannot be detected using other imaging techniques.
"Nuclear medicine is helpful when animals have a low-grade nondescript lameness that is hard to localize," says Pease. "For example, when bone is injured, it will heal. But this process may not be severe enough to see on an X ray, though it is still causing pain and lameness. On scintigraphy we can see bone damage and healing, but we don't know exactly how bad it is or why it is damaged--we just know it is a site where bone is undergoing remodeling. We can follow up with radiographs, ultrasound, CT, or MRI depending on how bad the lameness is, to further characterize the problem."
Standardizing the way images are transmitted and viewed is the key to rapid communication between veterinarians and improved communications with clients. Thus, veterinary practices are using the same imaging technology standards as human radiologists. "The American College of Veterinary Radiology requires that the imaging technology we use is DICOM (Digital Imaging and Communications in Medicine) compliant," says Pease. Like a PDF for business documents, DICOM is a standard format for distributing and viewing any kind of clinical image, regardless of where it originates. With DICOM, images can be sent around the world and viewed with a DICOM reader or on a private portal on a Web server.
"Digital imaging technologies have had an impact on every aspect of veterinary practice," says Susan Werner, practice manager at Werner Equine in North Granby, Conn., and a management consultant who helps other veterinarians assess new technologies. "The explosion of information technologies (for gathering, storing, and sending digital information) has enabled us to dramatically improve the quality of care, but it brings challenges for the equine practice as well."
For example, digital imaging requires less upfront time--the veterinarian and client can see the image instantly--but it requires more "behind the scenes" management and technology. "If you have that much more information, then you must figure out how you are going to record it, store it, access it when you need it, and decide who is going to access it and how you are going to share it," says Werner.
The Internet The Internet makes information available instantly, and access to it via broadband and wireless technology revolutionized communications for everyone, including veterinary practices. With more information immediately available to clients, Werner sees the veterinarian's role changing from a "paternalistic" one, in which the client "does what the doctor says," to that of an experienced practitioner who shares useful information and can help interpret the information coming from many new sources. "The Internet has a lot of misinformation," says Werner. "Owners are turning to their veterinarians and other professionals (farriers, trainers, etc.) to assess what is accurate and true."
"People now want to understand what was done, why it was done, and what they can do to take care of the horse," says Werner. "The veterinarian now has both the tools and the responsibility to help them understand."
Information Sharing As a management consultant, Werner has been examining technologies that can improve the quality of client services. She believes there are ample opportunities offered by these new technologies that can enhance veterinarian-client communication and translate to better care for horses.
"A doctor, whether he or she is a physician or a veterinarian, wants to create a medical record as soon as possible," says Werner. "We use a lot of acronyms and abbreviations for medical terminology that are not appropriate for the client. Standardizing terminology and information helps create comprehensive and interoperable medical records that improve the quality of patient care and client services."
SNOMED (Systemized Nomenclature of Medicine Clinical Terms) is a terminology system for human medicine that was originally devised by the College of American Pathologists. The system provides standard terminology for diagnosis, clinical procedures, and other medical terminology.
Adopting standards such as SNOMED can help veterinarians improve client communications, according to Werner. Using this system, software can replace the "doctor speak" abbreviations and acronyms in an invoice or aftercare sheet. This makes the instructions very clear for the client, while preserving the correct terminology in the official medical record.
Technology can also help maintain confidentiality, according to Werner. "For example, medical records software allows us to designate who we can speak to about the case, and whether or not we should discuss the case with others."
Personal Technologies Laptops, tablets, cell and smart phones, and iPads are all part of a trend toward instant communications that can be both advantageous and challenging when caring for equine patients. Mobile technologies can help veterinarians communicate with office-based networks, providing instant access to both their own data and an international network of equine veterinary expertise, according to Werner.
Instant communication via e-mail and texting seems like a natural way to communicate with veterinarians, particularly for younger people who have grown up with these technologies. "This can be a challenge to veterinary practices," she says. "Very often, these conversations contain information that should be part of the medical record." An accurate medical record is key to the quality of patient care and also is part of practices' insurance ¬requirements.
Recent years have seen an explosion in digital technologies for acquiring, viewing, recording, storing, and transmitting clinical information in equine veterinary practice. "This is a really exciting time to be in veterinary medicine, because there is so much to do," says Werner. Equine veterinary practices are working hard to evaluate and harness all of these technologies for the health of the horse.
|Imaging Technology Summary|
|Technology||How It Works||Uses||Advantages||Disadvantages|
|Radiographs (X rays)||A high-energy electromagnetic wave is sent through the body using a device that generates the high-wavelength photons. X ray-sensitive film behind the area that is being imaged converts the photons to light on the other side of the body structure, forming an image much like a photograph negative.||Detecting bone fractures and lesions||Bony or dense structures are easy to visualize||Soft tissue details are not routinely visible|
|Scintigraphy||An injected radioactive agent binds to specific structures. A special camera detects the radiation emissions from the patient as it moves across the body and records the images on a computer display or film.||Generalized view of the body for detection of low-level of bone remodeling, kidney function, or vascular profusion||Provides a good overview of the body||Does not show specific problems; must be followed up with other modalities|
|Computed Tomography (CT)||Uses X rays to generate three-dimensional sections of the body.||Identifying dental problems, complex fractures, head trauma or soft tissue lesions (with contrast medium)||Easy to see complex structures and ability to perform 3D imaging||Like X ray technology, soft tissue details are not as visible as bone|
|Magnetic Resonance Imaging (MRI)||Uses a magnet and radio frequencies to detect water in body structures.||Identifying causes of lameness, including navicular disease, suspensory ligament injuries, and other soft tissue injuries||Provides high-detail images of soft tissues and disease processes||Requires specialized equipment and personnel; not as useful for bone detail|
|Ultrasound||Uses sound waves to penetrate soft tissue and provide an image.||Identifying soft tissue injuries, abdominal organs, chest and heart problems, and blood vessels||Works well with radiographs; good for visualizing joints, tendons, and ligaments||Does not penetrate bone, requires specialized training, and is very user-dependent|
About the Author
Nancy Zacks holds an M.S. in Science Journalism from the Boston University College of Communication. She grew up in suburban Philadelphia where she learned to ride over fields and fences in nearby Malvern, Pa. When not writing, she enjoys riding at an eventing barn, drawing and painting horses, volunteering at a therapeutic riding program, and walking with Lilly, her black Labrador Retriever.
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