Trends in Alzheimer Imaging & Management

In this discussion, Dr. Lawrence Tanenbaum and Dr. Osman Ratib, Founder and CEO of Agora Care delve into the challenges of image management and explore how a more patient-centric approach to image storage and management could offer tangible solutions.

Creators and Guests

Host
Lawrence Tanenbaum, MD, FACR
Dr. Tanenbaum is a long term collaborator with the medical imaging industry, with interests in developing applications of contrast agents, MR, CT and advanced rendering in the clinical practice of medicine focusing on efficiency, radiation dose appropriateness and physiologic imaging. Dr. Tanenbaum has authored approximately 100 scholarly and peer reviewed articles, continues to chair educational and academic meetings and has delivered over 1500 invited lectures around the world.
Guest
Osman Ratib, MD
Professor Osman Ratib is dual board certified in cardiology and Nuclear Medicine and carries a doctoral degree in Biomedical Physics in digital imaging. In 1998 he was appointed as Professor and Vice Chairman of the Department of Radiology at University of California Los Angeles (UCLA). In 2005 he returned to Geneva to take the position of Head of Nuclear Medicine, and in 2006 he was appointed as chair of the Department of Medical Imaging and Information Sciences. He has pioneered several innovative projects including advanced cardiovascular PET-CT program and the first whole-body PET-MRI unit in Europe. He is also founding member and president of the OsiriX foundation, a non-profit organization for the promotion of Open-Source software in medicine. Founder and director of the Translational Molecular Imaging Institute in Geneva, funded by the Rolex/Wilsdorf foundation, affiliated to the University of Geneva and EPFL in Lausanne.

What is Trends in Alzheimer Imaging & Management?

Moderated by Lawrence Tanenbaum, MD, FACR, Applied Radiology hosted a series of conversations with experts in Alzheimer disease imaging and management at the 2024 Radiological Society of North America Annual Meeting and Scientific Exhibition.

Larry Tanenbaum, MD:

Welcome, everyone. We're live here at RSNA twenty twenty four. And I'd like to welcome you to the applied radiology roundtable series on the latest trends in Alzheimer's imaging and image management. For this module on image management in Alzheimer's patients, I'm joined here by my friend, doctor Osman Retib, the founder and CEO of AgoraCare. Osman, can you share the story behind AgoraCare?

Larry Tanenbaum, MD:

What inspired you to get involved in this area? You know, you're a radiologist like I am. How did you how did you find this inspiration?

Osman Ratib, MD:

We all know how difficult it is when you have to go back and retrieve images of a patient for the historical and and comparative images. For many years as a chair of department of radiologists, you know, we we try to get these old images so that we can compare them with the current one. It's even more important for chronic disease, Alzheimer, cancer, cardiac disease, where we need to repeat studies over and over and make sure that we have enough backup to see what has happened between those studies. It's complicated. So current systems in hospital don't provide that because patient go to different places, they have their study somewhere, then they go to the hospital, you have to create the data from it.

Osman Ratib, MD:

So that what generated the idea, why don't we just create a bank and give it to the patient? By giving the data to the patient, we have all the data at one place. And whether the patient stays with the same doctor or goes to another hospital, he still carries his data wherever he goes.

Larry Tanenbaum, MD:

I can't tell you how passionate I am about this particular issue. You probably know. My mom is, you know, in and out of imaging facilities and, in and out of different doctors. And it is incredibly painful when they want to repeat the exam they just did yesterday. You know, it's difficult, particularly when you're paying out of pocket or there's radiation involved.

Larry Tanenbaum, MD:

You know, that continuity of care is very challenging. As you know, I I was the chief technology officer for Adnet for years, and we even had joint venture partners where we had trouble getting the images from the hospital that informed us in the outpatient setting. That's a very, very big deal. So, can you expand a little bit on how you see this playing out in Alzheimer's patients and all the surveillance that they're getting on these disease modifying therapies? Well, we see

Osman Ratib, MD:

new treatments, new procedure for Alzheimer. We have now PETCT tracer. So we can be much more effective in predicting and following Alzheimer disease as it goes. And certainly, when we start injecting new drugs, new treatment, we need to follow how much of that is effective and how it's reducing the number of plaques. So that longitudinal follow-up is really becoming essential in those degenerative diseases where we now have treatments.

Osman Ratib, MD:

What we need to know, one patient may respond better than another one. We have variety of different treatment. So a follow-up study, even if the patient goes from one center to another, is essential.

Larry Tanenbaum, MD:

Yeah. Osman, I think you know that I'm very passionate about this particular issue, particularly in the Alzheimer's imaging space, because these patients are are going to be forced to get multiple surveillance examinations. If you don't have the prior study, the current study is virtually useless. Right? It's very, very important.

Larry Tanenbaum, MD:

And even if you needed to go to a different facility, they could at least be informed on what techniques they're actually using. Right? You don't wanna go as in a specific example, you don't wanna go to a facility that's using susceptibility weighted imaging to track hemorrhage when your previous follow ups are done with simple gradient echo imaging. It's really, an enormous problem. And, you know, also with this unique patient population, Osman, you know, they have often their care is directed by caretakers.

Larry Tanenbaum, MD:

You know, they're struggling in themselves to fit their elderly parents' needs into their day to day life. Chasing down images is is really problematic. So, Well, this is why we created an AgoraCare. AgoraCare essentially is driven by

Osman Ratib, MD:

the patient, but in elderly patient and in children, we take care our parents, our children will have to manage their father's or their children's dossiers. So they have to be able to collect the data and provide the data every time the patient goes to a new study. You just mentioned the protocols. Protocol evolves. The radiologist that needs to do the protocol today needs to know what protocol was used before that.

Osman Ratib, MD:

He may have a completely new protocol that doesn't match the previous one. Just having access to those data is essential. In my department, radiologists require that we have at least the prior study. It takes three full time people just to get data from other centers and to prepare the data, put them in the packs so that radiologists can do the proper study, especially with complex protocol like Alzheimer. If you go to PETCT, it's even more complicated.

Osman Ratib, MD:

You need to have the right tracer, right dose. If you don't have the prior data, you cannot generate a adequate study for that particular patient.

Larry Tanenbaum, MD:

You know, I couldn't agree with you more here. And I think it's particularly important in the Alzheimer's surveillance space. As you know, these disease modifying therapies, you know, do a wonderful job mobilizing amyloid with a really solid impact on cognitive impairment and slowing cognitive decline, even potentially arresting cognitive decline. But when you look when you give these therapies, you have a series of complications you need to look for. And is, you know, and they're basically related to, you know, brain edema and brain hemorrhage.

Larry Tanenbaum, MD:

But it's critically important that you detect and quantify these findings. The appropriate management of these patients depends on what has happened since the last visit. Right? Did I you know, you may have a few microhemorrhages, but how many microhemorrhages did you get since the last visit? And without the prior study at hand, you can't make that determination.

Larry Tanenbaum, MD:

And and

Osman Ratib, MD:

it is sometimes very subtle. It's not something that jumps at you. You really have to analyze the prior, as you said, number of hemorrhage, how it is. Now we're gonna see AI coming in. AI will help us also compare.

Osman Ratib, MD:

So what we didn't really we're not able to identify very subtle changes are now being quantified by algorithm. So, yes, we need to have that separate of access to prior access to the detailed images and not just the report of a prior study.

Larry Tanenbaum, MD:

I agree with that. And and frankly, this is, you you know, being going back to the patient centered story here. The folks that are getting these therapies are often very engaged, either the patients themselves or the the caretakers, the family members themselves. And they're very anxious to get the report that says all clear, you can go on to your next infusion. If you have to go through a three, four, five, six day delay so that you can get the old scan compared to the new scan in an AI application.

Larry Tanenbaum, MD:

And you mentioned the AI application.

Osman Ratib, MD:

I see.

Larry Tanenbaum, MD:

They're probably critically important here. As a neuroradiology community, we're not doing the best job detecting hemorrhage, detecting these edema, these unique changes in these patients. And these tools are very, very helpful at assessing the subtle findings. But the key point here is you need both exams in place so that you can apply whatever tool, either the human reading, the human, and the AI reading to make the critical determination. And patients are sitting on tenterhooks, on pins and needles, wondering whether they can go on.

Larry Tanenbaum, MD:

It's hard enough for the neurologist to coordinate care Absolutely. Without being able to get the answer quickly. And this type of a tool, which may gives the patient the power over their images, knows that where they go, the images go is very powerful. And you mentioned something about the patient has other diseases than just the Alzheimer. So as

Osman Ratib, MD:

you go into those treatment, you have to monitor other aspects like hypertension, like other diseases that could be a counter contradiction for giving a new dose of the disease for hemorrhage and other things. Not having all the other examination that were done separately like by cardiologist or by another center can be a risk for the patient. So not only you need the full history of the patient in terms of neuroimaging, but you need a complete medical history, and imaging is a key part of it. More than just report that says the patient has hypertension, you need to have the the proof of what is the status between different studies. And maybe order another study to just make sure that the patient is eligible for the right treatment.

Osman Ratib, MD:

So, Osmond,

Larry Tanenbaum, MD:

you know, I'm I'm very zealous about this approach, you know, giving the patient the control of the images. Can you talk to me about what makes AgoraCare special? If you have any unique technology that makes it easier to access the images? Well,

Osman Ratib, MD:

it is unique in a sense that most of the systems today in radiology center have a way to share the images or or give the image give access to the images. But you never have a repository that takes all the images from different center in one place. And most often, the patient have either CDs or a code for one center, for another center, and doesn't have the full picture. Goes to a doctor, doctor has to do the same work. So we are unique in a sense.

Osman Ratib, MD:

We have everything in one place, accessible everywhere. It's fully webbed, highly secure, and the patient is informed every time a new study is available so he can also notify his doctors. This is unique. It's basically the patient is the central node of all the caregivers, the the hospitals, and others, and they all share the same environment. I hope that model will also go beyond just imaging.

Osman Ratib, MD:

Today, we're focusing on imaging. This is our our expertise because we provide the tool for imaging. But this could apply to any lab result. Genomics, other data should be in the same repository. Pathology slices of biopsies is essential in other domains.

Osman Ratib, MD:

We need to grow from imaging to all the other omics and other imaging, provided to the patient.

Larry Tanenbaum, MD:

Now I love that approach. And, you know, to me, we've been thinking about the patients, but this somehow what you just described, does it somehow make it easier for the radiologist to see the images for the for the different, you know, different physicians that may be taking care of patients at a certain, you know, stage in their lives when they have multiple different

Osman Ratib, MD:

physician inputs? Yeah. Having access to the prior for radiologists is essential today. And having to go and get data from other center is really a pain. In my department, it was very complicated, and we couldn't dictate or report a study without having the prior if we know there's a prior.

Osman Ratib, MD:

The time that you waste in getting those priors is essential. And if you dictate the report without having looked at the prior study, insurance will tell you no. You have to go back and read it because

Larry Tanenbaum, MD:

As you know, we don't get paid for that second or

Osman Ratib, MD:

you get

Larry Tanenbaum, MD:

paid. It's extraordinarily annoying in a busy day.

Osman Ratib, MD:

You have to mention that you have seen this prior image and what you see today is similar or different. If you don't have that prior image, we facilitate. We have a big added value to radiology center because when the patient has an appointment for a for a new study, all the priors are available. We even have a way to synchronize AgoraCare with the center of radiology prior to the patient having a study. Everything that can gain time is essential for the patient.

Larry Tanenbaum, MD:

So from our discussions, it's clear that your long term goal is creating a global patient linked image repository for both clinical purposes as well as for research. Can you expand

Osman Ratib, MD:

on that a little bit? Well, we start with the idea that we need a clinical environment that helps the patient in his journey of being treated. But ultimately, once we grow and develop this large cohorts of patient, Alzheimer or others, we will certainly be interested to also solicit the patient to participate in research. We don't do it upfront. The patient gets an account without having to commit anything.

Osman Ratib, MD:

But as we have community of patients growing, we may have the opportunity to solicit those patient, get them consented, and have them participate into research. It's an advantage for the patient that can benefit from new treatment. It's an advantage for the research, academic, or pharma companies to have larger cohorts of patients with a full history, which is unique.

Larry Tanenbaum, MD:

So, you know, we've all heard about monetization of data. Is there something in it for the patients other than the greater good? Or is there something in it for them that they could they could get, you know, reimbursed for participating in research?

Osman Ratib, MD:

Well, there is different difference in different country. I come from Switzerland. In Switzerland, the patient cannot sell the data, but he can be compensated for participating in research. A certain amount of money depends on how much time he's gonna spend, if you have to answer questionnaires or give a blood sample, but we are not we or the patient are not allowed to sell the patient. In The US, the patient can request to be compensated for the data or it's a way of monetization, so he can get some return and that depends on the value of those data and what is his contribution.

Osman Ratib, MD:

The value also will depend on how much this will lead to a treatment that's beneficial to the patient. If the patient contributes to a a study where he himself is undergoing a treatment that is still being validated, of course, the value comes from that treatment, not just for the monetization of the data.

Larry Tanenbaum, MD:

You know, I would imagine that pharma and CROs would be very interested in this patient data repository. What have you heard?

Osman Ratib, MD:

Well, we heard that, for example, in Novartis, which is a large pharma in Switzerland, they had a very large initiative called DATA 42. So they collected all the data of all the research they had in one single repository so they can reuse the data. It didn't work because they didn't have the continuity with the patient that contributed to a study five, ten years ago because they haven't done don't have the link. We, in our philosophy, in our business model, we keep a link with the patient. We have what we call real world data attached to the patient.

Osman Ratib, MD:

If you need to solicit the patient after a study to have a follow-up, we can. We don't give away the patient identity. We keep that secret. The patient's always anonymous. But the investigator or the company that needs to have an additional contact with the patient, we request the patient to consent to that anonymously.

Osman Ratib, MD:

So we have this this link, but keep the patient completely autonomous and without any link to the investigator.

Larry Tanenbaum, MD:

So, doctor Atib, you are a Swiss company. You probably remember that I have Swiss family. Okay? You're trying to, you know, get a bigger footprint in The US or establish your footprint and grow a US business. Are there any unique regulatory challenges that are are that you're facing right now?

Osman Ratib, MD:

Not really challenges, but it's a different community. It's different business. The networks here are, let's say, health care network, are very oriented to managed care, which is a different model. We are starting to see that happening in Switzerland, but Switzerland is more of a of a private insurance type of model. So we have to adapt to those requirements.

Osman Ratib, MD:

But But one of the things that we bring to The US market is in those managed care networks, call them HMOs or others, the need to be able to make sure that there's no unnecessary examination or studies or or scans performed is key is key to the to reducing the cost and is key to avoiding having to repeat studies because in the managed capitated care, the cost the the value is value based, but not providing for every study cost. So it's this added cost, it's reducing the cost is very valuable here in The US market much more than in in Switzerland where it is.

Larry Tanenbaum, MD:

You know, I I love that focus because I'm just remembering my mother's incident of care recently. She had, a pneumonia. It looked really scary. It looked like a cancer. Alright?

Larry Tanenbaum, MD:

If you didn't have the old exam that was completely normal from a few weeks before, you would have thought she had a cancer. You would have told the patient they had a cancer. You might have even scheduled a consult with an oncologist, you know, anxiety, cost, and the like. But having the old scan was all the difference to tell her, don't worry. This is just a pneumonia.

Larry Tanenbaum, MD:

It's huge. Absolutely.

Osman Ratib, MD:

And you know, Larry, you know like me that images are becoming key for every diagnosis. And we need the images, not just the fact that there was something described as a pneumonia late. You don't know and basically, you see the images in every domain, whether it's a brain or or or cancer or abdominal disease. If you don't have an image to tell you what was there before, decision making here is difficult because you don't have the the proof of concept and the proof of the images. So images are becoming the real fine connections to the patient history.

Larry Tanenbaum, MD:

Do you have any other points that you'd like to add before I start to give you my my, fun summary of what we've talked about? Well, I would say that for us, it's

Osman Ratib, MD:

a new, adventure because we're not just going into the medical domain, but also into the research domain. And Alzheimer's typically an area where research is growing very rapidly. It's very exciting for us to have this opportunity to bring a new way of, providing data for those new drugs. This is gonna change the way we treat Alzheimer's. This is gonna be really a challenge to know which drug works better.

Osman Ratib, MD:

And we are very excited to be part of that. We have the right tool at the right moment.

Larry Tanenbaum, MD:

Yeah. I'm really excited that we got a chance to talk about this in the as part of our Alzheimer's series. But, you know, my basic feeling on imaging is that radiology is the center of the healthcare enterprise. It is. It applies in the hospital.

Larry Tanenbaum, MD:

It applies in the outpatient setting. And when you realize the information that we acquire in medical imaging is so critical, you don't leave it scattered around your house. You know, it isn't scattered around your bedroom. You keep it with you at a neat place where you keep all your important documents. We really don't have a facility to do this, and your organization is really going to bring this to patients.

Larry Tanenbaum, MD:

I think that's really important. I enjoyed the chance to to discuss today. I just like to say I'd like to it is probably is a good a time as any to wrap up our discussion on image management with a focus on patients, particularly as part of our Alzheimer's series. I'd like to thank my friend, doctor Osman Retib, for joining me in this roundtable series in the latest trends in Alzheimer's imaging and management, hosted by Applied Radiology with sponsorship from Siemens Health and Ears and AgoraCare. Osman, thank you very much.

Larry Tanenbaum, MD:

That was a lot of work. Harry.

Osman Ratib, MD:

It was a pleasure.