Imaging Update:
Technology Takes Diagnostics to the Next Level
Imaging has come a long way since the Greeks first utilized speculums to see inside the body. Hippocrates himself wrote of his experience utilizing this tool to visualize the rectum. Modern endoscopy’s precursor was ridiculed — in 1806, Philipp Bozzini used an aluminum tube to visualize the genitourinary tract. Lighted by a wax candle, the tube had fitted mirrors for reflecting, but it received scorn rather than praise.1
Diagnostic imaging now includes magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET), as well as ultrasound, nuclear medicine, picture archival communication systems (PACS), digital mammography, and molecular imaging. These imaging techniques continue to advance, with exciting innovations each year. The last three years saw a tremendous upsurge in its popularity and technological advances. However, such booms in the industry can lead to problems with over-utilization, introducing issues related to both quality and reimbursement.
Innovations
The HDTV signal from the new CV-180 video processor more than doubles the number of scan lines produced by conventional systems when used in conjunction with the new high-definition GIF-H180 gastroscope or CFH180A/ L colonoscope, so that the resulting images can provide gastroenterologists especially clear views of anatomical structures and fine capillaries.
Narrow-band imaging is a real-time, on-demand technology intended to enhance visualization of the capillary network and mucosal morphology during endoscopic observation of the gastrointestinal (GI) tract. NBI works by altering the white light source to consist of specific wavelength bands, which take advantage of the scattering and absorption properties of human tissue. This provides improved visual contrast of the surface structure and fine capillary patterns of the mucous membranes, which are normally difficult to distinguish.
“High-definition imaging was once the exclusive domain of professional cinematography and the consumer electronics world,” says F. Mark Gumz, president and chief operating officer of Olympus America Inc. “With the introduction of this groundbreaking system from Olympus, physicians will be able to see a greater level of detail during examinations, which may help to enhance patient diagnoses.”
These offerings are not limited to imaging for the GI tract. Olympus recently unveiled four broncho-video-scopes from the 180 series, which include NBI, slimmer designs and easier handling. And one model, the EVIS EXERA™ II BF-Q180-AC, can be sterilized in an autoclave.
Endoscopy is not the only area of improvement in imaging; image archiving is also critical to improving both cost and efficiency in today’s surgery centers.
“SourceMedical has seen a significant rise in the number of surgery centers and surgical hospitals interested in deploying and integrating diagnostic imaging capabilities with their core information management systems and electronic health record (EHR) systems, which makes our SourceRad PACS solution ideal for surgical environments,” says Joel Mezistrano, vice president of radiology. “Surgery centers and surgical hospitals are looking at picture archiving and communication systems (PACS) for the same reasons as hospitals and imaging centers: eliminating costly film, streamlining workflow, advanced visualization tools, and the ability to distribute images to remote locations. This is especially important for new facilities that have a unique opportunity to open their doors starting fresh with a paperless and filmless environment.”
Given Imaging offers the PillCam™, which enables diagnostic imaging of both the small intestine and large intestine. It can be used for visualizing the esophagus, stomach and small bowel, which is typically inaccessible to endoscopy and colonoscopy, or even in patients who cannot tolerate a traditional colonoscopy to assess the condition of the large bowel.
The capsule is essentially a camera contained inside a pill the size of a large vitamin, which is swallowed like a regular pill. The PillCam ESO has received a permanent CPT® Code assigned by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) that became effective Jan. 1, 2007; the PillCam SB is also widely covered in the United States.
The PillCam ESO (for esophageal imaging) and PillCam SB (for the small intestine) are equipped with two miniature color video cameras (one on each end), a battery and a flashing light source. In the PillCam ESO, the cameras transmit 14 color images per second as the capsule moves through the esophagus, and transmits approximately 2,600 images of the esophagus to a recording device worn by the patient. Data is transferred from the recorder belt to the RAPID® Workstation, which is used for viewing, editing, archiving, and e-mailing video images. It can save individual images and short video clips.
The PillCam SB capsule transmits approximately 50,000 images over the course of an eight-hour period (about two images per second) to a DataRecorder™ fixed to a belt worn around the patient’s waist. The small bowel images are then downloaded into a RAPID workstation computer where a physician can view the images on a video monitor and make a diagnosis.
GE Healthcare, a unit of General Electric Company, has re-imagined radiology, in a partnership with the Cleveland Clinic and AmSurg. The new agreement will help increase access to colon cancer diagnostic technologies for patients across the country. Together with AmSurg, an operator of single-specialty ambulatory surgery centers (ASCs), the three entities will work together to provide and interpret (CT) colonography technology, also known as virtual colonography.
Siemens Medical Solutions offers specialized ultrasound systems, some of which can be utilized for breast imaging. The ACUSON Antares™ ultrasound system* and innovative advancements in the ACUSON Sequoia™ ultrasound platform are expected to deliver increased imaging power, better patient outcomes and enhanced clinical workflow, according to the company. Siemens also offers its new X Class products with the ACUSON X300™ and ACUSON X500™ ultrasound systems, which have been designed to address ergonomic concerns of users and are equipped to handle a wide range of applications throughout varied environments.
Siemens also offers a mobile X-ray system that features integrated computed radiography (CR) reading technology. The MOBILETT XP CR was designed to enable bedside imaging. There is, further, a new advance in MRI, via the Tim® (Total imaging matrix) technology.
Tim technology is designed to eliminate the need for patient repositioning and manual coil changes during scans while significantly enhancing image quality, providing a solid foundation that continues to yield innovative new applications. The latest technology advancement powered by Tim is syngo TimCT, which offers Continuous Table Move for scanning comparable to CT, and is now available with Siemens T-class systems for the MAGNETOM Trio®, MAGNETOM Avanto® and MAGNETOM Espree™. This technology allows physicians to acquire one complete planning scan, or peripheral angiography, in a single, continuous move. With syngo TimCT, the table is not required to stay in a fixed position to acquire images.
T-class also helps improve workflow beyond the scanner with the new syngo Chorus MR, which integrates the MRI scanner into Radiology Information Systems (RIS) and Picture Archiving and Communication Systems (PACS), from data retrieval through distribution and billing.
Siemens has also introduced the AXIOM Luminos dRF, a new remote fluoroscopy system with flat detector (FD) technology, and announced enhancements to the AXIOM Aristos FX Plus, the company’s fully automatic digital radiography system.
Whole body scans are a relatively new invention, but are being embraced by not only the affluent, but also by many health-conscious members of the middle class. Preliminary research suggests that whole-body PET and CT scans could provide a suitable method for diagnosing the stage of colorectal cancer, according to a study in the Dec. 6, 2006 issue of the Journal of the American Medical Association (JAMA).
Because colorectal cancer accounts for a large number of tumor-related deaths, exact and complete information on the stage of the tumor is of great benefit to patients. Determining the stage of cancer often requires a multi-modality, multi-step imaging approach. Complete “conventional” staging determination requires additional imaging procedures to assess potential metastatic spread to lymph nodes and solid organs. Colonography combining the imaging procedures of positron emission tomography (PET) and computed tomography (CT) provides whole-body tumor staging in a single session.
Of conventional imaging procedures, contrast- enhanced CT is the most common for both the abdomen and the thorax. However, CT offers only form and structure data for the evaluation of the tumor stage. Combined PET/ CT scanners have been introduced into clinical practice to provide additional information on a tumor. By performing PET/CT colonography as a whole-body imaging procedure, multimodality diagnostic workup can be shortened.4
Overutilization
The increasing use of imaging in an outpatient setting has raised questions about overutilization. Insurance companies are taking notice, and there is the possibility that imaging reimbursement will decrease if they perceive that it is being claimed too frequently.
There is also the issue of non-radiologists utilizing the technology, raising the question of missed or mistaken diagnoses. Quality and safety are the watchwords of accreditation organizations such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care (AAAHC), so imaging may be on their radar as well.
Mezistrano says, “In the industry, there are several common criticisms of the use of diagnostic imaging technology in settings outside of traditional radiology departments or diagnostic imaging centers. Overutilization, outdated equipment, and quality concerns are issues that are commonly voiced. With respect to the quality of patient care, issues arise when specialists employ selective interpretation and focus on very specific areas of the studies. Here, PACS solutions with remote viewing capabilities can help by removing logistical barriers and enabling off-site radiologists or other specialists to do remote interpretation.”
The American College of Radiology (ACR) has expressed its own concern for the matter, stating in a 2004 report that the overuse of medical imaging procedures by less-qualified physicians lowers the quality of patient care, undermines patient safety, threatens the solvency of Medicare, and drains the American healthcare system of billions of dollars annually. James P. Borgstede, MD, chair of the ACR Board of Chancellors, told the U.S. House Ways and Means Subcommittee on Health that the ACR supports many of the recent Medicare Payment Advisory Commission (MedPAC) recommendations because current law is not effectively addressing a problem that is both damaging patient care and fleecing American taxpayers.
“We are deeply concerned by the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies to better their patients’ health,” he said. “The real harm is excessive exams and unnecessary exposure to radiation leading to a missed diagnosis, which can result in additional patient injury or even patient death.”
Diagnostic radiologists are medical doctors who are required to complete a minimum of four to six years of post–medical school education in all aspects of medical imaging, including formal training in advanced physics and radiation safety. Other medical specialties, currently performing medical imaging, require a range of imaging education, from as little as two days to a maximum of 10 months.
Diagnostic imaging is a $100 billion industry in the United States. Imaging is the fastest growing type of physician service expenditure in the United States, with an annual growth rate (9 percent) that is three times that of other physician services.
“Unaccredited, non-radiologist imaging facilities may use poor, perhaps malfunctioning equipment, and employ poorly trained technologists,” Borgstede said. “This raises material radiation safety concerns even though the adverse effects of these quality problems may not show up in the form of increased cancer risk, for decades.”
Another major concern for the ACR is that poor images taken by lesser-qualified personnel on suboptimal machines can have more of an immediate impact on patient care in terms of increased false positives, which further drain the health system to pursue nonexistent problems and increased false negatives, where missed diagnoses can delay or prevent timely treatment.
Borgstede also noted that inappropriate utilization of medical imaging procedures is a primary driver in escalating insurance costs. Premiums for family healthcare coverage have risen 59 percent since 2000, compared with inflation growth of only 9 percent. American businesses spend, on average, nearly $10,000 per employee for family healthcare coverage.
“Private insurers who have looked into this issue found a disturbing trend and took steps to clamp down on the practice,” Borgstede said. “A recent BlueCross/BlueShield study shows nearly a third of imaging performed by non-radiologists to be unnecessary, and another well-regarded study shows that number to be as high as 50 percent.”
The ACR supports many of the MedPAC recommendations that urge Congress to enact laws directing the secretary of Health and Human Services to set quality and safety standards for providers performing medical imaging, physicians interpreting these images, and facilities that bill Medicare for these services.5
The National Coalition for Quality Diagnostic Imaging Services (NCQDIS) also provided input to the House Ways and Means Subcommittee on Health in March 2005. The coalition, which is comprised of more than 2,400 outpatient imaging centers and departments in the U.S., called on Congress to address cost, quality and safety issues stemming from overutilization of diagnostic imaging by non-radiologists.
“In almost every congressional district in America, private insurers are improving [diagnostic imaging] quality and curbing overutilization using fairly simple tools, such as physician privileging and establishing quality standards,” said Cherrill Farnsworth, executive director of NCQDIS.6
The Pennsylvania Healthcare Cost Containment Council released a report, “The Growth in Diagnostic Imaging Utilization,” which confirms that the field of diagnostic imaging has advanced by leaps and bounds during the past 25 years.
A proliferation of diagnostic imaging equipment may translate into too much imaging, duplication of services, and financial excess. The equipment itself comes with a high price tag: an average MRI machine costs approximately $2 million to buy and install and $800,000 per year to run. The high cost of acquisition may create pressure to increase the volume of imaging done; doctors with their own equipment may have a financial incentive to order more scans.
Patients also contribute to higher utilization by requesting diagnostic imaging scans to relieve anxieties about their health. It is estimated that up to one-third of the nation’s healthcare expenditures are consumed by the “worried well.” Insured patients may not consider the high costs.
There are several strategies to help control the soaring costs of diagnostic imaging, including the following:
- Utilization management
- Physician self-referral restrictions
- Evidence-based practice guidelines
- Patient education
- Electronic medical records systems
It is crucial that both healthcare professionals and the business people who assist in the creation and management of outpatient centers monitor the need for imaging and its proper use — not over-saturating the market, but providing the service only where it is needed, educating patients about using imaging in the right place and time.