Medical Imaging

American Imaging Management’s David Harrington, CareCore National’s Dr Shelley N. Weiner, GE Healthcare’s Bill Radaj and Philip’s Kelly Londy discuss the challenges, trends and future of imaging technologies.

EHM. What are current and emerging trends in diagnostic imaging?

SW. Nuclear medicine is rapidly re-inventing itself as molecular imaging and is expected to make major advances in both diagnosis and disease management as new radiopharmaceuticals make their way through the pipeline and into the marketplace. PET/CT and SPECT/CT have already demonstrated the extraordinary value of combined anatomic and physiologic imaging. Radiopharmaceuticals can be designed to be taken up by abnormal cells carrying drugs to specific targets. The concentration of these therapeutic agents is increased in the abnormal cells and decreased in normal ones, therefore a smaller dose is needed to achieve the same effectiveness and at the same time decreases systemic side effects.

The evolution of computed tomography has only accelerated in the last few years as machines capable of more and more slices per rotation have been developed. Shorter scan times and the ability to rapidly image ever larger volumes of tissue have created capabilities undreamed of a decade ago.

MRI continues to advance in many directions. We will soon see the widespread emergence of 3T imaging with applications in the evaluation of common diseases such as dementia, attention deficit disorder, schizophrenia, as well as musculoskeletal pathology and new cardiac applications in the next few years. All while there is continuing development of applications based on current technology. At the other end of the spectrum is the development of smaller, less expensive MR devices aimed at a limited range of services. Extremity, breast and similar machines will spur added demand from non-radiologists to provide imaging services. This will predictably lead to increased utilization, misinterpretation, and litigation resulting in increased pressure for more supervision by professional associations, government, the public, and payers.

BR. First and foremost, CT is the clinical tool of choice for many acute situations, including trauma and chronic diseases. The current trend in CT, and one that has been dominating the industry for several years now, is balancing image quality with dose to the patient.

Traditionally, obtaining better images meant increasing radiation dose to the patient. But now we have technologies that enhance image quality while maintaining or actually reducing dose to the patient. With improved electronics, detector technologies and reconstruction algorithms, we can obtain better images without increasing dose.

As for emerging trends, we are focused on improving spatial resolution while following the ALARA principal in radiation exposure. In addition to developing advanced CT scanners, we will continue to create advanced applications such as cardiac imaging and analysis, colonography, and perfusion to help us achieve this goal.

KL. There are two areas of current and emerging trends. The first area is technology, which is evident in CT volume imaging where you see more of the body in less time with less radiation dose. Expanded molecular/PET imaging using enhanced molecular agents targeting specific organs and diseases, as well as cardiac non-invasive diagnosis with an expanded use of volume CT, are also key points to consider within technology.

The second area is macro trends that drive diagnostic imaging and there are five points within this area to consider:

• Age – as an aging population, we use the healthcare system more as we get older
• Lifestyle – in general the population is becoming more overweight, requiring more use of imaging
• Chronic illness – this is derivative of age and weight (diabetes, COPD, chronic heart disease); chronic illness is rising significantly
• Construction – majority of hospitals in U.S. are old, built around systems that are antiquated ($25B/year healthcare construction market to update facilities and equipment)
• Development of clinical information systems as a response to changes in treatment of patients along a disease-specific model

DH. The evolution of imaging is moving forward at an astonishing rate. CT is a great example, a 16-slice machine was state-of-the-art in 2002 and now a 256-slice scanner will hit the market. Beyond current modalities, you can look at the work in areas such as molecular imaging and nanotechnology and see that imaging will fundamentally change the way that medicine is practiced.

The dissemination of high-tech imaging equipment is another key trend. Previously, CT or MRI machines were confined to large hospitals, and then the equipment moved to smaller hospitals and large physician groups. Now, you can find machines in small practices or even individual physician offices. The cost and size of the equipment have both decreased enough that the number of machines in the market has exploded—with a predictable increase in utilization.

From an executive perspective, the key question is: how do we stay ahead of these changes? It doesn’t matter if you’re a health plan, hospital system, physician group or imaging management company - the future is fast approaching and all of us need more data, more information and more understanding in order to manage optimal use of diagnostic imaging.

EHM. Healthcare providers have been criticized for inappropriately utilizing imaging technologies. What are the reasons for this?

BR. In our experience, there are inadequate universal protocols to clearly guide clinicians in selecting and performing CT or other diagnostic imaging exams. With advancements in diagnostic imaging, such as laptop-sized portable ultrasound equipment, physicians have more choices than ever in choosing accurate, fast and convenient imaging technologies. Protocols could help guide physicians in choosing the most appropriate imaging technology for their patients.

Often, the clinician is acting independently to determine the best course of treatment for the patient. This can result in unnecessary multiple studies on one patient. However, establishing proper imaging protocols can offer the opportunity to save money and time. For example, using CT for aiding in coronary assessment instead of traditional cardiac catheterization can reduce time to diagnosis.

KL. Diagnostic imaging is the primary tool for many diseases and injuries and recent studies show use of imaging technologies decreases overall cost of healthcare. Over utilization is a key point that can come from many sources including protection from litigation and inappropriate use of imaging procedures by inexperienced users.

DH. At AIM, we see high-tech imaging orders that are duplicative and clinically unnecessary. At the very least, these orders are wasteful and a poor use of resources. At worst, they’re unsafe for patients. There are a couple of drivers for this issue.

Most physicians order a low volume of high-tech imaging, maybe one to five services a week. If you don’t use imaging very often, it can be difficult to keep up with the appropriate uses of the evolving technology, leading to inappropriate ordering. In these cases, provider education can have a significant impact.

System inefficiency is another issue. We see duplication occur because a physician is not aware that a patient has recently had an image taken, or because poor communication between the ordering physician and the radiologist leads to the wrong image being taken.

The movement of imaging into the physician office has increased utilization without any clear clinical benefit. Physician ownership of imaging equipment is defensive medicine gone wild. Everyone—government, health plans, even the medical societies—recognizes this issue. The amount of growth may still be open for debate, but I don’t think that anyone disputes that this is happening and that it is a problem.

SW. The field of medicine has been flooded with new drugs, new procedures, and research into the basic and applied science of disease. There is an endless supply of journals, newsletters, and manufacturer advertising. Just keeping abreast of one’s own specialty is a considerable achievement, simultaneously keeping track of a burgeoning field like medical imaging is nearly impossible. I think the most common reason for the inappropriate use of imaging is overestimating the value of certain exams.

Adding to this is a desire to avoid error at all costs - defensive medicine. For the average practitioner there is no reason not to order another exam, even if it is exceedingly unlikely to alter the course of patient care.

In other instances, there is a basic misunderstanding of the value of a positive or negative result. For example, breast MRI exams are often ordered to avoid an unnecessary biopsy when a biopsy is the only reasonable course. Physicians are not aware that, although breast MRI is very sensitive, it comes with low specificity resulting in more negative biopsies and patient anxiety as well as increased costs.

Rendering physicians also shoulder some responsibility for inappropriate imaging, and for many of the same reasons. Radiologists tend not to advise their referrers that a particular exam is inappropriate claiming that to do so may alienate the referrer. For the most part, radiologists do what is ordered without regard to the likely value of the order. Radiologists often oversell the accuracy or value of certain exams thereby increasing demand. Finally, responding to their own desire to avoid error, radiologists frequently include recommendations for further exams in their reports, often without an in depth understanding of the necessity, appropriateness, or value of their suggestions.

The role of the public should not be underestimated. Influenced by advertising, news media, and word of mouth, patients often request expensive imaging procedures when their physicians know that the test is unlikely to be useful.

In summary, there is plenty of responsibility to go around.

EHM. What are the implications of inappropriate utilization of imaging technologies for patients as well as healthcare providers?

KL. The implications for patients are that there is potential for unnecessary radiation dose and unnecessary cost. For providers there are capacity and cost issues. Finally for US healthcare in general, inappropriate use is a key driver to the overall cost (healthcare costs now stand at approximately 16 percent of GDP), and a continued rise will ultimately cause federal government to step in and regulate healthcare.

DH. First and foremost, inappropriate imaging is a patient safety issue. A number of these studies expose patients to significant amounts of radiation. A CT of the abdomen, the most common request we receive, exposes patients to the radiation equivalent of 500 chest x-rays. The average amount of radiation received by Americans has increased by 750 percent over the last 25 years, primarily due to imaging. The American College of Radiology is now recommending that something be done to track the cumulative levels of radiation exposure from imaging in order to avoid excessive exposure.

The use of the wrong imaging modality is another issue. CT and MRI are not inter-changeable; each one has particular uses for which it is the superior modality. Without provider education, it is not uncommon to see an order for one modality, followed almost immediately by an order for the other. Once again, this creates both clinical and cost implications for patients.

SW. There are two potentially negative consequences to patients from inappropriate imaging.

First, there is exposure to radiation and contrast agents. While for any individual the likelihood of an untoward result is small, when you consider that millions of such exams are done every year, it is clear that there is real risk to the population as a whole. In April 2007, the National Council for Radiation Protection reported that diagnostic radiation exposure, mostly due to CT, rose six fold over the last twenty years.

Second, imaging studies may lead the doctor and patient in the wrong direction. Over reliance on a negative report may forestall the early diagnosis of cancer and can lead to unnecessary studies and procedures. The Agency for Healthcare Research and Quality estimates that in women, with a positive mammogram, negative breast MRI cancer was missed 4 percent of the time. Early imaging of back pain can lead to surgery for disc herniations clearly seen on the MRI, but which had nothing to do with the patient’s pain.

Finally, there is a distortion in the economy of medicine. Modern medical imaging is expensive. The diversion of capital into a sexy new 3T MRI device, while beneficial to a limited number of patients, means that there are fewer resources available for more mundane pursuits, such as preventive medicine programs that benefit many. Increased expenditures for imaging services reduce funds available for primary care providers. Medical economics may not be a zero sum game, but the dollars available are far from unlimited, and once a dollar is spent, it cannot be spent elsewhere.

BR. The implications of inappropriate utilization can’t be underestimated. First, it creates unnecessary financial burdens for both patients and healthcare providers, and can contribute to rising healthcare costs. Second, it boosts patients’ risk of increased exposure to ionizing radiation.

However, proper utilization of imaging technologies can help enhance quality of care and can potentially offer the opportunity to reduce the time to diagnosis.

EHM. How do your solutions help customers and partners overcome diagnostic imaging management difficulties?

DH. AIM’s primary responsibility is to ensure the safety and appropriateness of the diagnostic imaging received by the members of our clients, and to achieve that objective as quickly and efficiently as possible.

Our clinical program evaluates imaging requests against current evidence-based guidelines on imaging use, and assists physicians in improving their use of imaging through education at the point of order. Our analysis of clinical indicators helps our clients understand the important trends that are impacting them, their network and their members.

We have designed our process to be non-intrusive to the patient-physician relationship. We work with physicians to gather complete information during our initial interaction in order to identify and approve appropriate requests. We are the leader in using the Internet to increase the efficiency of our processes. We have over 60,000 providers using our provider portal, and processed over one1 million prior authorizations over the Internet last year.

In addition, we are continually looking to partner with our clients to develop products and programs to transform the old-fashioned way and alleviate the complexity of managing imaging. One example is our OptiNetSM product, which provides tools to manage imaging networks more effectively and paves the way for transparency.

SW. CareCore National’s approach to diagnostic imaging management combines utilization and quality programs. Together, these two components create synergy and improve the diagnostic efficacy received by patients.

The most powerful tool in utilization management is prior authorization of high-tech imaging services. Using proprietary criteria that are constantly updated, we ensure that the patient’s clinical picture supports the need for an imaging study.

This process fosters better utilization in two ways: 1) exams ordered without clear indications are not authorized, and 2) perhaps of equal effectiveness, ordering physicians are incentivized to be more circumspect in what they order. It is of no value to a doctor to devote the time and resources needed to complete a prior authorization request if he or she knows that it is unlikely to meet with approval. Having ordering physicians eliminate inappropriate exams based on their own judgment is the sentinel effect, which while difficult to measure, represents the goal of any management program.

We also advocate limiting, to the extent practical, imaging performed by non-radiologists. We believe there is sufficient evidence that this decreases utilization without diminishing care, and improves the quality of imaging services rendered.

CareCore National’s quality management programs include setting standards for imaging equipment, requiring board certification of interpreting physicians, and accreditation of imaging laboratories by national organizations. We actively review imaging exams for technical and professional quality, and inspect imaging sites for conformity to established standards and practices. By requiring sites to meet high quality standards, we reduce uninterpretable and repeat examinations, poorly constructed and confusing reports, and erroneous interpretations. These are problems that can never be eliminated, but must be addressed in an imaging management program if it is to be effective.

To make our programs more transparent and acceptable to physicians, we conduct meetings with both rendering and referring practices to discuss issues as they arise, and to foster better understanding of our goals and processes.

BR. We have developed a broad range of products – from scanners and workstations to applications and IT systems – to help clinicians manage a variety of diagnostic imaging challenges. These dilemmas run the gamut, from acquisition and analysis to dissemination of vast amounts of digital data.

To manage acquisition challenges, our consistent user interfaces between diagnostic imaging technologies make our systems fast and easy to use. In addition, we’ve improved acquisition speed to allow facilities to boost patient throughput and more effectively handle emergency cases along with already busy schedules. This, in turn, helps facilities improve workflow.

We also have developed sophisticated IT solutions that help facilities manage the large amounts of data from diagnostic imaging scans. For example, now physicians can save data from the workstation to a CD to share with other doctors or the patient.

Whether physicians need to acquire, analyze, share or archive information, we have a product to help control that process. These products seamlessly interface to help physicians easily manage data throughout a healthcare enterprise.

KL. Our solutions are aligned with our providers’ need to justify outcomes of patient care. They provide integrated solutions along a disease-specific or clinical segment, including the alignment of information technologies and imaging modalities. This results in lower cost (to provider), increased productivity and the ability to better manage outcomes as well as more efficient utilization of information, images or data to all caregivers across the clinical segment.

EHM. In the future, where do you see the areas of biggest potential for medical imaging? Likewise, what will be the biggest challenges for healthcare providers?

SW. The answer to both parts of this question is cardiac imaging. Recent advances in CT, MRI and PET technology for imaging the heart are already available and those in development present new possibilities for the diagnosis and treatment of coronary artery disease, and other cardiac conditions.

The biggest challenge for healthcare providers will be applying these examinations appropriately, cost-effectively, and safely. Many of these new and developing technologies have overlapping applications. The challenge is to understand how to select the correct study in order to obtain the information needed without performing redundant and costly examinations that do not contribute to patient management. Another challenge is to ensure that providers of imaging services have the training and expertise to perform high quality examinations.

BR. At GE, we believe the biggest potential for the future lies in “early health” – the opportunity to identify disease processes earlier in their development and to define the proper imaging procedure or protocol to address the disease state.

The biggest challenge is simply the cost of healthcare. Paying for services, coping with declining reimbursements, handling complex billing, and working with insurance companies will continue to take a toll on our industry.

We believe in shifting resources from managing symptom-based, advanced disease to developing technologies that allow healthcare providers to diagnose disease at the earliest possible stage, when there can be many treatment options. Then treating the disease with proper intervention or medication, and continually monitoring that clinical disease state.

We are developing technologies that will enable clinicians to provide more promising options to patients. For example, CT imaging may help physicians visualize plaque that may be an early indicator of cardiovascular disease and subtle vascular changes that may be predictive of stroke.

This is not just better medicine. It also makes simple economic sense.

KL. The potential for the future, is that diagnostic imaging will be able to lower the cost of healthcare, make definitive diagnosis of injury or disease faster, have less invasive procedure and greater utilization of non-invasive and molecular testing. Medical imaging will become central point of patient management.

Challenges include managing in a disease-specific environment and this requires changes in governance at provider level. Providers must figure out how to organize all physicians to work in disease specific arenas, for example, Cardiology or Oncology, instead of by department, for example, Radiology, Emergency, or Critical Care.

Further challenges include appropriate capacity of imaging equipment in an age where we’re getting older, bigger and increasingly sick as well as providers having a difficult time measuring outcomes and performance across their systems.

DH. The on-going evolution of imaging will offer significant opportunities for improving clinical care. It will also increase the complexity of using this technology and the need for continued emphasis on ensuring appropriate imaging use. Similar to other types of clinical interventions, when used properly, imaging has tremendous potential and when used inappropriately, imaging can have a negative effect on the clinical process.

On a broader note, the impact of technology on diagnostic imaging offers a potential model for the overall healthcare system. The improving diagnostic capabilities, the movement to digital technology, the miniaturization of equipment, and the integration of information systems have radically transformed imaging. Several of these areas of impact - improving communications and information transmission, the movement to connectivity and interoperability - set the stage for an electronic highway that can and should be emulated in other parts of our healthcare system.

“This is not just better medicine. It also makes simple economic sense” – Bill Radaj

“Medical imaging will become central point of patient management” – Kelly Londy

“The cost and size of the equipment have both decreased enough that the number of machines in the market has exploded” – David Harrington

“The biggest challenge for healthcare providers will be applying these examinations appropriately, cost-effectively, and safely” – Shelley N. Weiner

Shelley N. Weiner, MD, FACR
Senior Vice President/Chief Medical Officer, CareCore National
Dr. Weiner oversees the training and education of staff physicians as well as the development of radiology imaging criteria at CareCore National. She chairs the company’s Utilization Management Committee. Dr. Weiner received a Bachelor of Arts degree from Mount Holyoke College in 1968 and a Doctor of Medicine degree in 1972 from the State University of New York Downstate Medical Center. She interned at Montefiore Medical Center and completed her residency in diagnostic radiology at the Albert Einstein College of Medicine in 1976. Dr. Weiner became board-certified in diagnostic radiology in 1976 and in 2005 was certified by the American Board of Quality Assurance and Utilization Review Physicians. Prior to joining CareCore National, Dr. Weiner practiced radiology in both academic and private practice settings.

Bill Radaj
General Manager, CT Commercial Operations, GE Healthcare
Bill Radaj is the General Manager of CT Commercial Operations for GE Healthcare. Bill began his career in the CT marketing organization, and has been with GE for 19 years. Throughout his career, he has held positions as the Installed Base Marketing Manager and High Field Marketing Manager for MR, as well as the Region Sales Manager and Americas Marketing Manager for CT.

David Harrington
David S. Harrington brings over 30 years of successful experience in all areas of health care management. He is a valued leader, analyst and consultant, particularly for entities seeking to initiate or remediate health service ventures. Mr. Harrington is rare among senior healthcare managers having held executive positions with health plans, hospitals and physician-owned enterprises.

As CEO of American Imaging Management (AIM), Mr. Harrington led a dramatic turnaround by emphasizing technology as the driver for enhancing AIM’s clinical and service capabilities. Under his leadership, AIM has become the most innovative company in the radiology benefit management industry.

Kelly Londy
Kelly Londy is currently the Vice President and General Manager of the CT and NM Business Lines in North America. In this role she is responsible for the sales and marketing teams for both of these businesses.

Before moving into her current role, Kelly was the Vice President of the Strategic Business Group (Strategic Business, GPO, Government, Channel Strategy and Entrepreneurial Businesses) for Philips Medical Systems North America and reported to Brent Shafer, CEO, Philips Medical Systems, SSR NA.

Kelly was Zone Vice President of Strategic, in Central Zone, for Philips Medical Systems North America and reported to John Desch, Vice President of Strategic Business for 3 years prior.

Ms. Londy brings 17 years of experience in health care administration and the medical technology marketplace. She also has served at General Electric Medical Systems on the Strategic Business team. Additionally, Kelly was a MR Product Specialist and National MR Manager for SP while at GE Medical Systems.