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Taking Diagnostic Imaging Centers to a New Level

Siemens' SOMATOM Emotion 6 has a slim, wide-open CT gantry that provides easy-to-use, fast, high-quality CT.

Like many other health care providers, diagnostic imaging centers (DICs) operate in a challenging market. Competition is high, margins are tight, and qualified staff is scarce. These conditions sound all too familiar in today's health care market, but DICs face some extenuating circumstances. In the last 5 to 10 years, many small independent practices have joined forces to form large groups. These conglomerates have reduced the overall number of players in the market and allowed remaining DICs to take advantage of economies of scale.

Radiologix Inc (Dallas, Texas) is one of the masters of the economy-of -scale concept. The company is one of the largest nationwide providers of radiology services; it consists of freestanding multimodality imaging centers and managed radiology practices. Currently, the company operates 115 freestanding radiology centers and provides them with strategic materials, operations management, marketing, information technology, customer service, and technical expertise. Radiologix employs an innovative hub and spoke arrangement, in which a local site assumes administrative and marketing functions for a group of centers. The end result is an efficient diagnostic imaging enterprise.

This comprehensive approach could be the wave of the future. Why? Competition among DICs is stiff, which is what happens when smaller practices merge and pool their resources to enter new markets. A few years ago, a one- or two-center practice might not have had the capital or the drive to undertake a new venture on another provider's turf. Today's larger operations, however, are not necessarily constrained in the same way. In fact, it is not uncommon to find two or three DICs on the same street. The competition does not end among DICs, though, as DICs compete with hospitals as well.

The ultra-competitive environment isn't the last of the challenges faced by DICs. The day-to-day business of a DIC can be somewhat unpredictable. Because centers need to provide same-day service at their facilities, they must maintain open slots every day, which can translate into higher operating costs. In contrast, a patient at a hospital facility could wait a week or two for a routine appointment. Consequently, the onus to maintain high patient throughput is on DICs.

Of course, DICs do face some of the same issues as their hospital peers. Take the technologist shortage. Both hospitals and DICs must deal with the reality of an extremely tight technologist market. Hence, the sharpest players in the DIC market have recognized the need to streamline techs' workflow and provide them with user-friendly equipment.

The final factor in the DIC equation is customers. DICs, like all health care enterprises, need to provide patients with a quality experience. A freestanding site with a flexible schedule is not enough to remain competitive in today's market. Patients are knowledgeable about health care issues, and state-of-the-art equipment is a must. Moreover, the DIC must educate referring physicians and patients about its capabilities.

In Search of DIC-Friendly Technology
One way for a center to differentiate itself from the competition is to employ advanced technology. Radio-logix recently purchased and installed Siemens Medical Solutions' (Malvern, Pa) SOMATOM Emotion 6 CT scanners at several of its centers.

Donald Pelton, vice president of materials management for Radiologix, explains, "We want to plan as far ahead as we can for a fixed investment. Financially, the Emotion 6 made great sense for us. It's a mega, multislice, yet [it's an] affordable scanner. Siemens is doing a great job in the market with this piece of equipment."

The new Emotion 6 scanner represents the ideal CT package for DICs. It offers the full functionality of high-end CT, including such advanced clinical applications as abdominal, neurological, orthopedic, and pediatric imaging. Other features of the Emotion 6 include the ability to perform routine angiography with integrated 3D visualization tools.

The Emotion 6 is relatively easy on the budget, but Radiologix had other reasons behind the decision to implement the scanners. Its small footprint, ease of installation, reliability, reduced patient dose, and low costs per exam made it the ideal choice for the DIC network. In theory, these are excellent reasons for purchasing any piece of technology. And in practice, Siemens' Medical SOMATOM Emotion 6 has delivered.

For starters, Pelton affirms, "the scanners are reliable and have been easy to install." And Siemens' service has kept the scanners up and running. Also, budget-conscious administrators are more than satisfied with the low cost per exam with the scanner.

The specifications of the Emotion 6 CT are impressive and provide ample reason for DICs to choose the scanners. But other factors often come into play for DICs as they evaluate new CT solutions. DICs should consider asking the following questions, which, along with the price, will help point a DIC in the right direction:

• Does the vendor strive to work as partner with a DIC? Does it understand the environment?
• Has the vendor delivered quality equipment in the past?
• What are the equipment specs and capabilities? Does it offer the desired packages?
• What is the lifecycle cost of the equipment?

The Emotion 6 CT certainly translates into reduced costs per procedure, contributing to bottom line results, and it boosts business in other ways as well. The advanced functionality of the Emotion 6 allows DICs to expand into new clinical markets. With the ability to perform CT angiography, DICs can easily grow the physician referral base and provide advanced clinical services to cardiologists and internists. The Emotion 6 gives referring physicians a high level of confidence in a center's expertise in performing more complex studies.

The ability to enter new, niche markets gives Radiologix a competitive edge. Pelton asserts that the advanced functionality of the Emotion 6 is fast becoming a necessity. "In some past instances, DICs did not need all of the bells and whistles," he explains. "But imaging is becoming more virtual. Our centers need to reconstruct, transmit, and utilize in 3D. With the Emotion 6, 3D reconstruction can be fast and effortless."

Another factor in the DIC financial equation is throughput, and the Emotion 6 line clearly meets the demands in this arena. Pelton is overseeing the installation of several Emotion 6 scanners. "In each market, we anticipate the same outcome," he says. "The speed of the equipment gives us the ability to scan patients more efficiently without sacrificing patient care or service. [We also can] provide more procedures each day, thereby increasing the number of procedures we can achieve."

This healthy increase could well be worth the investment in the new technology, but it is likely just the tip of the iceberg. The limiting factor to increasing patient throughput is not scan time, so technologists at Radiologix, for example, are working on ways to improve their patient flow and scanning efficiency.

The Comprehensive DIC Vendor
It isn't easy being a DIC. Numerous challenges exist, including competition, high operating costs, the technologist shortage, and savvy customers. The last thing any profit-minded DIC needs on its plate is additional challenges related to equipment. These hurdles, unfortunately, come in all too many flavors. Top on the list might be unreliable equipment. For some unfortunate centers, this scenario is all too familiar. A scanner is booked for the day, but mysteriously goes down at 9 a.m. Appointments are shuffled or cancelled, which frustrates both techs and patients. The patient might, in turn, share the experience with the referring physician, who, next time, could opt to try that other DIC down the street.

Technology quandaries play a part as well. Any imaging technology is only as good as the operator, which means user-friendliness is absolutely key. Defining that term, however, is something of a moving target. Some vendors might tout their user-friendly solutions. But older, DOS-based systems can be quite challenging. Or each piece of scanning equipment could have its own look and feel, hindering the technologists' learning curve when new technology is implemented, further complicating workflow.

Finally, the one-size-fits all approach is one that some vendors seem to espouse. Some vendors can be blind to the unique needs of DICs. They might have a good package, but it could be the only package they sell. And DICs not only differ from hospitals; they also differ from each other. The right equipment for one center might not work in another. So finding a flexible vendor who can work in a partnership relationship is critical for DICs that want to move to the next level. "Siemens," Pelton says, "has a very good understanding of the DIC market."

Radiologix, for instance, has chosen to work with Siemens and found that the company understands its needs. Over time, the company has installed each type of Siemens scanner: high-field MRIs, open MRIs, CT scanners, and nuclear medicine cameras. The common link among the modalities is Siemens syngo software. Pelton asserts, "We might not have bought these units if they didn't have a common operating platform. It's really important to us."

The Windows-based platform is shared among most Siemens imaging modalities and is associated with a number of benefits. Because syngo is Windows-based, it is very trainable for technologists. They also can maneuver through the various systems to keep workflow going. Techs can move from center to center with ease, and training new technologists on the system is quite simple. Finally, syngo's user-friendliness can enhance job satisfaction and help DICs retain valuable employees.

Siemens' commitment to the common syngo platform is matched by a complementary commitment to offering its DIC customers affordable, flexible solutions. Emotion 6 technology can be tailored for various markets, and Siemens encourages customers to devise solutions that meet their individual needs. For example, Radiologix has tailored Emotion 6 CT scanners for specific markets. One scanner might be built for speed-a bread-and-butter scanner that can handle a multitude of patients quickly. Another Emotion 6 scanner might be designed with a full array of features for cardiology procedures.

Pelton and his Radiologix colleagues see the Emotion 6 playing a key role in the organization's future. "We're excited about this equipment," he admits. "It will take us to another level in what we are able to offer to patients and referring physicians."

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Optimizing Workflow

A major focus of the workstations from Siemens is on efficient, intelligent workflow.

Diagnostic imaging centers (DICs) and hospitals might operate in somewhat disparate markets, but they do share some common objectives. Streamlined workflow often tops the list. "Workflow is crucial to the success of our department," asserts Chris D'Angelo, CT coordinator for Alamance Regional Medical Center (Burlington, NC). "A radiology department can have the best equipment in the world, but without good workflow, it doesn't mean anything."

Alamance Medical Center stands out as a model of streamlined workflow. In the last 3 to 5 years, the hospital has seen a significant increase in patient volume, and it routinely handles 45 to 60 CT patients in a 7:30 a.m.–4 p.m. day. Patients spend an average of 5 to 10 minutes in the scanning room, down from 25 minutes a few years ago. D'Angelo explains, "We've become very skilled at streamlining workflow. Luckily, we gave a good scanner that can handle our volume."

Inside the Streamlined Department
D'Angelo and his colleagues rely on a Sensation 16 CT scanner and syngo software from Siemens Medical Solutions (Malvern, Pa) to meet their challenging workflow requirements. The software incorporates streamlined, pre-programmed protocols; few changes are required for each protocol, and syngo features automated 3D post-processing and multi-planar reconstruction (MPR) tags. An autotasking card on each protocol automatically sends the data and presets the MPR and 3D ranges.

Implementing Siemens' imaging solutions has resulted in significant timesavings for Alamance's CT techs. A combination of the fast acquisition time of the scanner and the automated protocols and post-processing translate into a tremendous increase in workflow. With Siemens' automated protocols and InSpace technology, a cardiac CTA at Alamance requires a mere 10 to 15 minutes from scan to post-processing. "There's no longer a difference between a specialized study like a CTA and a routine study because they're all fast," D'Angelo notes.

syngo offers another workflow plus. The software expedites training of new techs, even those who have never seen it before. D'Angelo boasts that he completed training for a temporary CT operator in a mere two days before sending her off to work solo.

The Radiologist's Perspective
Workflow is multifaceted. The day-to-day considerations exist, like throughput and post-processing. And then there are the big picture considerations of providing clinicians with timely and relevant answers. Joseph Collins, MD, head of the body CT section at Mayo Clinic (Scottsdale, Az), says, "The radiologist is becoming a central point for medical care in this country. This is true even though the radiologist does his best work through the hands of others."

Radiologists are facilitating better patient care, and it is more efficient and less expensive than it was five years ago. The CT scanner is abso-lutely crucial in this new streamlined environment. In the last three years, the number of CT exams at Mayo Clinic has exceeded the combined number of MRI, ultrasound, and nuclear medicine scans. Collins explains that the CT scanner has become the answer machine, because it casts a wide net, it's fast, and it is reproducibly consistent.

The implications for the CT specialist are tremendous. "I am much more productive than I was 5 years ago," Collins admits. "I look at hundreds more images every day. I produce images far superior to those produced 5 years ago, and I'm providing referring physicians with better, more accurate, and more thorough interpretations."

Technology certainly deserves a fair amount of credit for this increase in productivity. Five years ago, multi-detector CT scanners (MDCT) had not yet hit the streets, the first picture archiving and communications systems (PACS) were brand new, and electronic medical records (EMRs) were either not yet implemented or fragmented into subsystems. Film, along with its accompanying archival and transportation issues, was the mainstay of radiology departments. Voice recognition was not yet in place. "Every single piece of that has changed," Collins confirms.

MDCTs are common, and radiology information systems (RIS) have matured. Now the radiologist has complete patient EMRs at his fingertips. PACS enables electronic display of current and past images, and dictation is completed with voice recognition. The radiologist can extract much more information from a CT scan than he could in the past. The upshot is the complete transformation of the radiologist's job. Collins explains, "The radiologist's job is almost like a sculptor. He needs to carve away the excess to display the relevant information so that anyone can look at the image and perceive the problem.

"The challenge," he continues, "is diving in and extracting the key questions and elements to create a concise, accurate, and relevant report. In each case, the radiologist needs to wisely choose when or if to use advanced 3D techniques." These intelligent reports must be created in a streamlined fashion to maintain workflow.

In the larger workflow picture, however, it often makes sense for the radiologist to invest time upfront to enhance workflow across the hospital. This outlook often entails thinking like a surgeon. For example, in the case of colon cancer, the radiologist utilizes advanced 3D techniques to identify the lymph nodes and liver metastases. It is probably time-consuming initially; however, the end results are enhanced workflow and patient care. A second or third study is not ordered to identify pathology that could be found on the first. This approach also saves the surgeon's time, because he is provided with the comprehensive, timely information that he needs.

The Next Frontier
For all of the advances and timesaving tools and techniques, radiology departments crave even greater efficiency. This lofty goal can be achieved in a number of ways. The future undoubtedly holds more automation and faster reconstructions.

Collins looks forward to the ideal workstation. The ultimate solution might be a cross between a PACS workstation and 3D workstation. Right now, he says, 3D CT workstations offer better features than PACS workstations. The PACS workstation, however, provides the means to export images and holds the archive. He admits, "We need a PACS workstation with all of the capabilities of a 3D workstation or a 3D workstation that can pull in the PACS archive and push images." Also on Collins' wish list is speed and added simplicity.

According to D'Angelo, "The next biggest challenge will be to take autotasking another step. In other words, to bypass standard axial reconstruction and go right to volume rendering and multi-planar reconstruction. The next generation of scanners might be able to generate all of the multi-planar ranges and volume rendering during scanning. I think Siemens is headed this way, and it will be amazing."

Such highly advanced scanners are just one piece of the futuristic, streamlined radiology department. Siemens continues to innovate-not only enhancing current products, but also developing new solutions to meet the challenging workflow and clinical demands of its radiology customers.

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CT Colonography: Mapping Uncharted Areas

Siemens' Multislice CT scanners, combined with the syngo colonography package, allow for comprehensive visualization of the colon.

CT colonography is a non-invasive imaging technique that simulates interactive endoscopic viewing of the colon. Users of CT colonography recognize that the technology carries a number of advantages. For starters, patients tend to accept the test more readily than its conventional counterpart. It also takes less time to perform a CT colonography than the traditional procedure. It allows evaluation of colon lesions and polyps in the early stages before they become clinically significant.

Nevertheless, implementing CT colonography into clinical practice does come with its challenges. Physicians need to gain an understanding of the technical and clinical requirements necessary to effectively implement a CT colonography program as well as develop a consistent and streamlined workflow system.

On the technical side, the bar for CT colonography workstations and software is extremely high. Michael Macari, MD and associate professor of Radiology at New York University School of Medicine (New York City), explains, "CT colonography workstations must be very fast to load up the cases and a lot of images. If you have a slow workstation, you can forget about CT colonography."

The need for speed derives from several factors. To begin with, the workstation should allow the physician to view 2D and 3D images simultaneously, so he can cross-reference data from both types of images. Another key feature is the ability to simultaneously evaluate supine and prone images. This feature ensures that the colon is actually distended for evaluation. A final software requirement is the ability to change window level settings to optimize and evaluate regions of interest.

Siemens Medical Solutions' (Malvern, Pa) syngo Colonography application meets these demanding requirements. Macari notes that the application incorporates a number of features to distinguish its performance from other products. Siemens' 3D flythrough mode is user-friendly, and its surface-rendering program simulates the colonic surface in a realistic way. The application also enables easy cross-referencing of the 3D image to the 2D MPR. Finally, a convenient "marker" feature allows the user to review all suspicious areas discovered during the flythrough and convert them into a report, which includes measurements, location within the colon, and an assessment of the likelihood that the defect is a true polyp.

Although radiologists might universally agree about the need for speed in a CT colonography package, some ambiguity exists about the ideal workflow setup for CT colonography. Some readers prefer to view 2D data sets and employ 3D for problem solving; other readers evaluate data with a 3D virtual flythrough and utilize 2D for problem solving. Macari says both methods are currently acceptable. He estimates that 80% of readers currently use the primary 2D view/3D problem-solving method, mostly because it is faster than the primary 3D/2D method, which requires four evaluations. "These preferences could change in the future," he predicts. In fact, because of these different user preferences, Macari has a recommendation to sites that are considering CT colonography software: Shop for a package that allows both primary 2D and primary 3D evaluation of data sets.

Vendors like Siemens are continuing to fine-tune colonography software to make it easier for radiologists to implement the technology and improve management and treatment of colon cancer. Efficient, high-speed workstations with robust features are one part of the solution. Physician education and a commitment to developing and delivering a comprehensive solution are equally important.

The Missing Link: Colonography Education
An ultrafast workstation and an effective workflow are absolutely key to effectively implementing CT colonography. The other, equally important, aspect of the equation is education.

Colonography is an excellent fit for a range of practices-radiology, gastroenterology, and internal medicine. However, strong ties to referring physicians are necessary to add a successful virtual colonography into any practice. A radiology practice that has a solid working relationship with gastroentorologists and internists are in a good starting position. The next step is helping the referring physicians understand colonography.

One of the drivers for colonography is patient demand. As virtual colonography continues to receive consumer media coverage, patients will ask primary physicians about the technology. But if the physician is not educated about colonography, the patient could be misled and steered away from colonography. For example, the physician might mistakenly tell the patient the test is not effective or that he is not a candidate for the procedure.

For this reason, a comprehensive education campaign targeting referring physicians is necessary. One of the keys to successful implementation of colonography is educating physicians about its value, its role in the continuum of patient care, and indications for referring patients for virtual colonography. The educational program can be used as a multipurpose tool that not only educates the referring physician base, but also grows a new virtual colonography practice. An ideal way to launch a comprehensive physician education and marketing campaign is through partnership with a vendor that understands the nuances of the technology and market.

Siemens works with practices to ensure smooth implementation of its colonography package via on-site application training. The company also provides post-sale assistance with education and marketing efforts. This flexible program can be arranged around a practice's specific needs and typically includes marketing information, technical guidelines for physicians, and content to use in letters to referring physicians.

Looking into the Future of Virtual Colonography*
In some ways, CT colonography is a work in progress. The evaluation of colon data sets remains somewhat challenging, but a number of tools on the horizon could help facilitate CT colonography implementation and workflow. In fact, Siemens is directing research and resources into a number of tools to facilitate and improve CT colonography. Advances on the colonography horizon include polyp segmentation and computer-aided detection (CAD). These tools could boost the clinical utility and acceptance of CT colonography.

Computer-aided detection, with its outstanding success in mammography and clear relevance for colonography, seems to top the list of futuristic, must-have colonography tools. Polyp segmentation, however, could be an even greater advance.

Polyp segmentation eliminates the tedious and time-consuming steps of manually outlining lesions. How does it work? Polyp segmentation provides a rapid way to quantify a lesion after a polyp was identified. An automatic volume measurement tool incorporated into colonography software is an ideal way to quantify a lesion.

The next step after polyp segmentation is CAD for colonography, which would function similarly to breast CAD. That is, it would aid radiologists by marking suspicious regions for further analysis. With colonography, the radiologist would complete a regular reading in 2D or 3D to assess for polyps. After the initial interpretation was complete, the computer would analyze the data to identify and mark potential lesions for further review.

The utility of a second reading in screening mammography is unquestioned; CAD improves breast cancer detection rates by more than 20 percent. And observational oversight can plague any radiologist reading a large volume of cases, whether they are mammograms or virtual colonography images. It also can assist radiologists as they work through the colonography learning curve. NYU's Macari explains, "CAD will be very helpful to people without a lot of experience."

Electronic cleansing is another prospective colonography tool, but it might be a little farther in the future. This advance would entail automatic removal of the stool from the image. The patient could drink a contrast that labels stool, and the computer removes the stool from the images.

Some vendors have recognized the need to develop a comprehensive virtual colonography package that includes electronic cleansing, CAD, and polyp segmentation. "These are all important tools," Macari says. "Siemens is working with us on CAD, segmentation, and fecal tagging. The company is very committed to providing a comprehensive virtual colonography package."