The 3D Imaging Lab:In-house or Outsource?

Staying abreast with (or, better yet, staying ahead of) the imaging-technology curve clearly follows a clinical imperative. Better imaging tools—in this case, 3D postprocessed reconstructions—have an immediate payoff for patient care. When a surgeon can use 3D imaging to measure and plan a vascular procedure better, for instance, the clinical outcome may be enhanced. Both patient and surgeon will then be rewarded, but so will the institution that offers the imaging service. This is so frequently true that hospitals and health networks often opt for imaging-technology upgrades long before the financial reasons become apparent. Marketing clout and patient satisfaction can override direct ROI considerations. One example is the 3D-imaging lab set up by Spectrum Health in Grand Rapids, Mich. Spectrum Health, organized in 1997, comprises seven hospitals and is Western Michigan’s largest not-for-profit health system. It had operating revenues in fiscal 2007 of about $2.3 billion, according to its Web site. About four years ago, Spectrum committed to opening Western Michigan’s first (and still only) full-time 3D-imaging lab. Demand for the lab came partly from clinicians and the radiology departments of various hospitals, but an equally important impetus was Spectrum’s vision of itself as a provider. “The opening of the 3D lab was part of the vision,” Shannon Culver, RT(R)(CT),the imaging specialist in charge of the lab, explains. “Our goal is to be up there with, or surpass, places like Massachusetts General Hospital, Stanford, and the University of Michigan.” According to a Spectrum vision-statement excerpt provided by Culver, that goal was explicitly stated: “To be the nation’s highest quality and most successful health care enterprise by 2010.” Culver himself was working at Spectrum as a CT technologist when he heard of the plan to open the 3D laboratory. He had already started work on a degree in computer information systems in order to add technology-related skills to his CV, he says. What he knew about 3D postprocessing and reconstruction intrigued him. “I started to come in during the middle of the night and volunteered to learn it,” he says. “I was doing that for several months.” Watching the radiologists and learning from the 3D workstation vendor’s application specialist, Culver spent 15 to 20 hours per week reading and researching to get a better understanding of the fundamentals, and then sending samples to the radiologists for their review. Culver was rewarded for his efforts by being named the new lab’s specialist, effectively, running the new lab. He began by doing CT reconstructions. The lab has since hired a second specialist to do MRI reconstructions. The lab does no ultrasound reconstruction, Culver says. One Room When the lab opened in 2004 at Spectrum’s Butterworth Hospital in Grand Rapids, it was located in a single room, where Culver worked alone. He now has his fellow worker, but the room is the same, measuring perhaps 15 by 20 feet. Culver says that there are now seven 3D workstations at locations throughout the various Spectrum hospitals, but the 3D lab itself contains three of them. All use a thin-client server, with postprocessing application software residing on the server and accessed remotely through the workstations. Images from as many as 10 CT scanners are autorouted to the 3D lab when postprocessing is required. The CT mix includes four 64-slice machines, but reconstructions are done using images from scanners with as few as 16 slices. “We do everything from trauma injuries to pre- and postsurgical planning,” Culver says. “Most of it is an accessory to the original radiology dataset. Our vascular surgeons used to take their own measurements, but then they realized we could do the measurements for them, right off our workstations.” When the images come into the lab for reconstruction, they are accompanied by patient histories, which technologists have sent by fax. “I do the reconstruction and send it out for interpretation to another hospital and the radiologist’s office.” When the reconstructions are sent, the patient histories are sent again, by fax, along with them. After that, Culver says, “The reconstruction will automatically append to the original study on the PACS.” According to a Spectrum brochure on the 3D lab, the enhanced renderings can “minimize exploratory surgery, allow for noninvasive surgical planning, reduce operating time, minimize damage to healthy tissues by targeting treatment areas, and aid in postsurgical evaluation.” Those benefits can apply to abnormalities in coronary, gastrointestinal, and neurological vascular structures, as well as to the vascular system as a whole. The 3D renderings can also be done for thoracic, orthopedic, pediatric, and maxillofacial conditions. Culver says, “We do a lot of head and neck vascular studies (carotid and circle of Willis) and urography. That would be the lion’s share: neurology and urography.” What the 3D renderings allow the radiologists or the clinicians to do is look at multiple projections of a structure. “They can twist and turn and manipulate the images around a stenosis and get a better feel for the significance of it,” Culver says. “They can look from one end, left to right, right to left, bottom to top, and top to bottom. They could take a volume-rendered image and rotate that right around.” Better Care Culver says that the 3D lab has, without a doubt, improved patient care at the Spectrum sites. The volume of 3D studies has increased dramatically. When he started, Culver says, he was postprocessing about 30 CT studies per month. Now that figure is above 350 for CT, and MRI adds another 250 monthly. “It has significantly increased the quality of the care provided to patients,” he says. “There are big benefits when doctors have added tools.” Moreover, he adds, as word of the lab gets out, patients are seeking 3D renderings as part of treatment. “The patients are starting to ask for it,” he says, “especially more along the lines of the cardiac side. The community awareness is starting.” Culver and his fellow MRI reconstructionist can’t work around the clock, but Spectrum keeps the 3D lab open at all times, priding itself on being the only Western Michigan caregiver to do so. To meet the off-hours demand, Spectrum has trained Butterworth Hospital technologists on every shift to complete the most common 3D renderings. “For the off shifts and weekends, each lead technologist has been trained to accommodate emergency services (carotid angio and head angio),” Culver says. “Each lead technologist is more than qualified, and we try to go two deep on each shift, if possible. There are seven people, other than me, who are capable of stepping up when needed.” When Culver arrives in the morning, he reviews the off-shift reconstructions and makes sure that all the overnight 3D work has been finished. “My job is to make sure nothing slides through,” he says. Red or Black? For all the clinical success of its 3D lab, an isolated and direct ROI for the lab alone has not been calculated, as far as Culver knows. In part, that’s because so many of the 3D procedures are billed as part of the original study. The postprocessing is coded so that it is automatically added to the original study; the charge for 3D postprocessing is not broken out of the bundled billing. “If we do a CT angio of the neck, or any angio, there is an inherent postprocessing charge built right in,” but figuring the cumulative payoff of such charges “is so hard to put your finger on,” he adds. Just as difficult to fathom as the reimbursement side is the cost side. Culver says, “Cost is very subjective.” For one thing, he says, the price of 3D workstations is often bundled into the purchase price of a scanner. Postprocessing software prices may be another enigma. Some postprocessing applications, such as software for cardiac studies or virtual colonoscopies, are more expensive than others. It’s hard to draw a straight cost-revenue line with such complex equipment, he suggests, adding, “I couldn’t say at what point it becomes cost effective.” Black Ink Nonetheless, Culver is adamant that the 3D lab is more than paying its way. He not comfortable putting a price on what it cost to equip the lab, suggests that the figure probably exceeds $500,000. Offsetting that cost, however, is what the lab bills. While he can’t isolate each bundled charge, Culver estimates that the lab bills in excess of $1 million per year. Even if reimbursements don’t add up to that level of billing, he adds, there is more than enough reimbursement to put the lab in the black. “We definitely come out ahead,” Culver says. “We’re not operating at a loss in here, and I say that based on our volume.” He also says that the lab has absolutely repaid the investment that it required. The lab’s volume “has been a steady trend upward,” he says. Moreover, the lab is pulling in business, he adds, with urology, cardiology, and pediatric studies keeping patients from going to other facilities. He notes, "As referring physicians become aware of the services, it’s been a steady trend upward, with no end in sight. As computers evolve, we’re on the cutting edge, and the sky’s the limit.” Culver again references Spectrum’s vision statement. “Spectrum did this for a reason, and we’re not losing by doing it,” he says. “It’s propelling us to the front of the pack when it comes to advanced visualization.” As far as Culver is concerned, ROI analysis can wait. The 3D lab has more than paid off on Spectrum’s goal of providing the best patient care in its market.