Articles & White Papers

    Thinking Strategically About Imaging Capacity and Capital

    Griffin, David and Dubiel, Paul. Radiology Management, Jan./Feb. 2006, p15.

    Executive Summary

    • Diagnostic imaging continues to place high demands on hospital
      and health system capital budgets due to the high cost of most
      equipment and the rate of technological change.
    • Diagnostic imaging also can be a significant service in competitive
      positioning, both alone and in conjunction with other programs and
      services.
    • The purpose of this article is to provide a framework for linking
      diagnostic imaging to key hospital programs, and for forecasting
      future demands and capital requirements. The model has been
      developed over time in a number of settings in the United States
      and Canada. The specific examples are mostly f rom the Seton
      Healthcare Network in Austin, TX.

    Read the full article

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    Trends in Diagnostic Imaging

    The major drivers in Imaging Technology and Services as we look to the future are discussed below in general order of immediacy.

    1. PACS and related digital imaging systems. Most hospitals are at some stage of PACS planning and/or implementation. It will soon be an imperative in order to manage the exploding volumes of images created by the newest technologies (e.g. CT and MRI) and to provide enhanced quality and service. All specialized modalities are already digital: angiography, ultrasound, CT, MRI, and nuclear medicine. Most fluoroscopy systems purchased in the last 5-7 years are digital or digital capable. The last two “frontiers” are general radiography and mammography. Digital systems are available and in use for each, although equipment is 3-4 times more expensive than conventional equipment.

      Digital radiography is thus usually brought on line when full PACS is implemented. It is of two types: CR (computed radiography) and DDR (direct digital radiography).

      • CR uses cassettes loaded into the table like a film cassette. The image is captured digitally and “discharged” from the CR plate into electronic format using a CR reader (a process akin to film developing). This is slightly more efficient than conventional film. In the long run, CR is a transition to DDR for most providers, although in will continue to be more cost-effective in lower volume providers.
      • DDR has electronic sensors built into the table. As soon as an image is taken, it appears on a monitor in the room. There is thus no manipulation or “development” of cassettes, which can be the most time consuming parts of many exams. DDR equipment is also highly automated with preprogrammed table/tube manipulations. DDR will significantly improve patient throughput, if the support systems are in place to move patients in and out of rooms as rapidly as practical (change/waiting spaces close to rooms and support staff to manage patient flows).

      Adoption of digital mammography is in the early stages; however it will be the standard in 5-8 years. Computer assisted diagnosis (CAD) will become prominent as an adjunct, providing a second read for screening mammography. Tomosynthesis will provide 3D breast images from digital mammography.

    2. CT. CT was introduced over 30 years and has undergone numerous advances, but no time period has seen changes as rapid and profound as the last few years and looking ahead at least ten more. Procedure volumes have been growing at least 10% per year, a trend that may accelerate in the next five years. Multi-slice CT (MSCT) was introduced in 1998 and has rapidly evolved from 2>4>8>16>32>64 slices with 128 and 256 on the horizon. The end point is flat panel detectors which provide "infinite" slices.

      16 MSCT changed the paradigm since it permits volumetric (3-D) reconstruction with high resolution. Radiologists no longer just read slices. This capability has opened the door to CTA vascular studies (peripheral, carotid, neuro, renal, and aorta) and virtual “oscopies” (e.g. colonoscopy, bronchoscopy).

      64 MSCT is opening the door to cardiac CT and coronary artery imaging (and improving all 3D studies). It is likely to replace diagnostic cardiac caths and expand the patient population being tested.

      Areas most affected by MSCT are:
      • Emergency medicine. Because of the speed of MSCT and the ability to scan multiple areas of interest in one exam, use will grow rapidly in the ED. It will be necessary to “dedicate” one MSCT to ED in larger hospitals and to make if very convenient in others. With three scans performed as a single procedure, it will be possible to triage chest pain between MI, pulmonary embolism, and dissecting aneurysm. Similarly, abdominal and pelvic scans can be used to triage an acute abdomen.
      • Stroke. A major element in the ED is rapid assessment of stroke in order to differentiate between occlusive and hemorrhagic stroke and to optimize therapy. CT perfusion and diffusion studies will provide the information needed.
      • Vascular disease, including carotid disease. CT angiography (CTA) will become the early diagnostic tool of choice impacting ultrasound and angiography. Angiography will be used primarily for interventions with known disease.
      • Coronary artery disease. CTA will be used early in assessment of early heart disease, and cardiac cath will be used for subsequent treatment. CTA will also be used to monitor patients post treatment (CABG, angioplasty/stent). The role of cardiac nuclear medicine will decline (due to MR as well).
      • Virtual colonoscopy. Although not quite as accurate as conventional colonoscopy today, problems will be overcome. More patients will opt for CT colonoscopy, and thus more patients will be diagnosed with disease and receive interventions using traditional methods.
      • Virtual bronchoscopy. This will be the procedure of choice for assessment of lung and other thoracic diseases. CAD will be important.

      These advances in CT are negatively impacting conventional imaging including radiography and fluoroscopy as well as emergency ultrasound and nuclear medicine.

    3. MRI. MRI came into clinical use about 25 years ago. It has experienced rapid growth at rates of 8-12% per year. Such trends will continue due to new applications resulting from magnet and gantry design, coils, and greatly increased computing speed. The clinical areas that are currently most significant for MRI are neurosciences, orthopaedics, oncology, and ENT. Newer areas of growth in the next 5-10 years are breast, cardiology, vascular, and interventional/minimally invasive procedures.

      • Breast MRI will become prominent, initially for high risk patients and ultimately prior to interventions. It will guide breast interventions for lesions that can only be detected by MRI.
      • MRI could become the gold standard in assessing cardiac function, having further negative impacts on nuclear cardiology.
      • MRI will complement CT in assessing brain function post-stroke and will be standard of care for all white matter brain diseases.
      • MRA will complement CTA for plaque/wall characterization.

      Currently the technical standard for general imaging service is a 1.5T magnet. Higher field strength magnets are moving into some community hospitals. Within 10 years, 3.0T will be the standard of care in larger community hospitals due its greater speed, higher resolution, and ability to perform functional studies. Specialized systems will become more prevalent including orthopaedic, breast, and head (3T).

    4. Fusion Imaging. Fusion imaging is the “marriage” of two modalities to provide a combined image. The general advantage is to combine structural and functional information into a single output. Fusion can be done with hardware or software. Software fusion requires that the two modalities establish several common reference points so that a program can overlay one image on the other. Hardware fusion produces both types of images sequentially on a single equipment platform.

      The most common examples are in nuclear medicine with SPECT-CT and PET-CT. PET/SPECT provides functional information about tissue properties/function/ viability. CT provides anatomical orientation.

      The most common applications for PET-CT are oncology for staging tumors, planning therapy, and monitoring recurrence. In the future it will be used mid-therapy (systemic) to determine response. At this time, there are virtually no sales of PET-only systems, and existing systems will soon be replaced.

      Some PET-CT systems are being used for treatment planning by smaller cancer centres with the CT component also used simulations. However as the utilization of PET-CT grows, the role in treatment planning will become one role for PET-CT systems in general.

      Future PET-CT growth will occur in neurology and cardiology. New markers are in development for SPECT-CT. The major impacts will likely be in cardiac imaging, but they could impact oncology and neurosciences as well.

      There continues to be significant debate about the role of CT and/or MRI in conjunction with Angiography, especially for newly developing neuro-interventional procedures. There are designs for suites with both modalities provided internally and others with CT and/or MRI adjacent to angiography. If these combinations develop, they will be located primarily in centers with major neuroscience services.

    5. Treatment. Imaging guided interventions have grown rapidly in recent years involving multiple imaging modalities. CT, ultrasound, angiography, and fluoroscopy are the primary ones. This has been part of the movement to less-invasive procedures performed in (hospital) outpatient settings. We will see continued growth in such procedures with some interesting new approaches.

      A combined MRI/ultrasound system has been in use in Europe for at least 5 years and was recently approved in the US. A continuous MRI image is used to guide a focused ultrasound probe (external) which heats and destroys tissue non-invasively. The initial application is for uterine fibroids, replacing hysterectomy. The procedure could be done in imaging in a room similar to conventional MRI.

      Other ablation therapies will continue to expand, including radiofrequency (RFA), cryo-ablation, laser-ablation, etc. Some will performed in imaging and some will be performed in procedural areas.

      Treatment planning will move to a new level with 3-D images generated by CT and MRI guiding more focused radiation, various types of surgical instruments, and robotics systems. Some will be real time; some will be off-line. Another variation will be surgical suites with CT or MRI scanners in close proximity so that surgical progress/outcomes can be evaluated in the peri-operative environment.

    6. Functional imaging. Most of imaging provides information about structure, the exception being nuclear medicine. Looking 8-15 years out, imaging will provide information at the tissue and molecular level in a variety of ways. Functional MRI and MRS (spectroscopy) are the clearest examples. However CT and ultrasound will also be used to characterize tissue. New types of functional studies will involve new imaging agents that are injected and activated in the presence of target cells or molecules. Cancer will probably be the earliest application, but neurology, cardiology, and other areas will follow. Current imaging modalities will see increased utilization, mostly CT, MRI, PET, and nuclear medicine. Entirely new modalities may emerge. Of all the trends identified herein, this will probably take the longest to devolve to the community setting.

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    Trends in Pathology and Laboratory Medicine

    The major drivers in Pathology and Laboratory Medicine Services as we look to the future are discussed below.

    1. Workforce pressures. With current labor shortages which will only get worse, there is a strong drive for increased productivity among the most skilled laboratory professionals: pathologists and technologists. A key strategy is to focus their time and efforts on the highest level of work, automating (see below) and/or redefining jobs:

      • The use of PAs by pathologists is becoming increasingly common.
      • Digital microscopy and telepathology will provide the capability to review slides remotely. This will make if feasible for pathologists to provide remote consultative services and allow them to cluster in groups with a critical mass of subspecialties.
      • Methodologies from other industries are finding their way into laboratory operations in order to increase productivity and improve service. The current “buzz-words” are Six Sigma and Lean. Many laboratories are being re-engineered according to these principles in order to make better use of highly skilled staff will maintaining or improving high service levels.
      • The role of the laboratory technician/aide is expanding. These duties can include specimen collection, specimen receiving/processing, instrument loading, slide staining, urine dipstick/chemistry, and microbiology plating. Some point of care testing may be performed by technicians. To make this efficient, the functions performed by technicians should be in a central/core part of the laboratory.
    2. Automation. Ever since the first automated chemistry and haematology analyzers developed in the late 60’s/early 70’s, laboratory testing has experienced steady increases in the level of automation, the speed/throughput of instruments, and the extent of test menus on a single platform. A single instrument today with a single operator/technologist can perform the tests formerly performed by as many as five instruments. More recently, most or all of the specimen handling functions have been automated in some form. Today we see:

      • Front end processing which can include the following steps: specimen receiving, centrifugation, sample splitting/labeling, and sample sorting and racking.
      • Total laboratory automation, which is cost-effective only in large laboratories. However more laboratories are adopting it as way to deal with labor shortages.
      • Islands of automation in which clusters of similar instruments work off a single specimen sampling module. These may be discrete instruments connected by a track, or multiple instruments may be housed in a common chassis.
      • New automation, e.g. automated PCR and histology tissue processing.
    3. Informatics. Since their introduction in the early 1970’s, laboratory information systems have rapidly evolved into essential elements of laboratory operations. Newer features include:

      • Electronic medical records, eliminating the need for laboratory and other paper charts.
      • Automatic verification of results, based on defined algorithms that require technologists to only have to review abnormal/atypical results.
      • Electronic cross-matching.
      • Hand-held devices for bedside positive patient identification in phlebotomy and printing of labels.
      • Docking stations for point of care instruments to capture all patient and quality control results.
      • Computer assisted diagnosis, which identifies areas of interest in various types of slides (urinalysis, cytology, and (eventually) anatomic pathology).
      • Digital microscopy with computer assisted diagnosis and PACS-like pathology systems.
      • Voice recognition to minimize the need to medical transcriptionists.
    4. Point of Care. The list of tests that can be done on POC instruments continues to grow, challenging laboratories and hospitals.

      • Additional critical tests such as troponin and BNP are being offered. Often the reagent/cartridge cost per test is very high, and efficient laboratory systems with rapid specimen transport can offer the same level of service at lower costs.
      • Some individuals believe that POC will result in a smaller laboratory. However, most POC of tests, when performed in the laboratory, are performed on instruments that can not be eliminated due to other roles.

      The laboratory is responsible for POC test quality regardless of who performs the tests. As POC grows the impacts on the laboratory include:

      • Create a position of POC coordinator (FT/PT).
      • Create workspaces for cross-over/validation testing, equipment storage (spares in the lab), and clerical/paper work.
      • Develop training processes and spaces, regardless of whether POC is performed by laboratory or unit personnel.
    5. Molecular Diagnostics. There will be rapid growth in molecular testing in ways that will complement existing tests and will replace others. The three broad areas of change will be infectious disease, genetics, and pathology.

      • Infectious disease testing will permit (more) rapid identification of pathogens and/or their susceptibility to particular drugs. These may be performed on primary samples directly or on cultured isolates. Most applications to date have been in virology, sexually transmitted diseases, and mycobacteriology (TB).
      • Impacts in genetics will be felt in academic and esoteric laboratories that focus on areas such as cytogenetics, tissue typing, etc.
      • All aspects of pathology will be affected: surgical pathology, cytopathology, and hematopathology. Molecular techniques will extend the array of tests performed on pathology specimens much as immuno-peroxidase staining has in recent years. Specific technologies will include PCR, FISH, and microarrays.
    6. Predictive Tests. A new set to terms has been developed based on the ability to determine the molecular and/or metabolic properties of tissue so as to “customize or personalize” therapy. While much of the early excitement is in oncology, it is reasonable to assume that such technologies will evolve into many other areas including autoimmune disease, neurological disease, etc. These will be developed at research/academic institutions, but may ultimately migrate to larger community facilities. In either regard, they will improve outcomes in areas that have heretofore been intractable.

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