Improving Referring Physician Access to Images and 3D Renderings
While many referring physicians have access to radiological images, certain subspecialists such as cardiologists want—and get—access to more sophisticated 3D images. Advanced software allows referring physicians to subtract various anatomical elements. Image provided by Vital Images.
Radiologists, administrators and IT professionals have worked hard to refine the acquisition, manipulation and storage of diagnostic images. But what about the special needs of referring physicians who increasingly want to access radiological images along with reports—including 3D renderings? Surprisingly, it’s not all that complicated.

The PACS route

Joseph Dilone, CIIP, CPAS, LMRT, ARMRIT, is the radiology administrator for 1960 Digital Imaging, an outpatient center in Houston, with five radiologists. The facility gets referrals from urologists, orthopedic surgeons, general surgeons, oncologists and others. Several years ago, Dilone and colleagues installed the AccessNet PACS from Aspyra. All of their referring physicians have the AccessNet ImageWeb viewer installed at their facilities that allows them to access the diagnostic images—anywhere, anytime.

Some referring physicians, such as orthopedists doing follow-up, are content with static images. Orthopedic surgeons, on the other hand, increasingly want access to interactive tools to manipulate, magnify and rotate 3D images. In those cases, Dilone tweaks the templates to give these subspecialists enhanced interactive image capabilities. Neurosurgeons and cardiologists command a more sophisticated access. Dilone sets them up on a virtual private network (VPN) so they can have access to high-resolution, diagnostic-quality, 3D-rendered images for precise pre-operative measurement and planning. They dial into a Vitrea workstation and can manipulate and rotate the images, as well as do fly-throughs.

Dilone recently set up a group of seven family physicians in nearby Tombalt, Texas, with the Access.Net ImageWeb browser for use on their tablet PCs. The group seeks to enhance point-of-care services for patients and now they are able to streamline patient care by having a quicker turn-around time of diagnostic information, Dilone says.

One referring physician, Philip L. Leggett, MD, a general and laparoendoscopic surgeon at Houston Northwest Medical Center, likes having access to CT scans of the chest, upper GI and colon, as well as MRI studies. “Before, we had to go to the hospital and pull the x-ray,” he says. “This is really a technology that benefits patients. You can make decisions while they are in your office. It expedites care.”

Leggett also likes that if he has a question about something in the report, he and the radiologists can look at the image together while they talk on the phone.

Maimonides Medical Center in Brooklyn, N.Y., is a 705-bed hospital with 18 radiologists and more than a dozen radiology residents. The facility has used the AccessNet PACS for more than a decade. Several years ago, they explored other PACS options but decided to stay with AccessNet, according to Maxine Fielding, assistant vice president for the MIS department at Maimonides.

Fielding says that within the last two years, the demand from referring physicians to access to diagnostic images has dramatically increased. All physicians within the hospital have access to radiological images. Most of them are taking advantage of it, Fielding says. Several groups, such as cardiothoracic surgeons, neurologists and ER physicians, can access images remotely. Referring physicians are able to perform rudimentary functions such as magnifying the image or rotating it. To manipulate 3D images, they must go to the radiology department’s 3D workstation. 

Outsourcing is an option

Borgess Medical Center, a 424-bed healthcare facility in Kalamazoo, Mich., experienced a dramatic increase in its CT volume. While the radiologic technologists were skilled at post-processing and 3D modeling, the increase in CT studies—and the concomitant increase in the need to post-process images—began to interfere with workflow. “It got to the point where our technologists were treating the 3D modeling as a deferrable task, something that could be done later,” says Radiology Director Tom Mushett.

Mushett and colleagues considered the option of creating an in-house 3D lab, but cost and space were an issue. While the department uses Vitrea advanced visualization software from Vital Images to create 2D, 3D and 4D images, it would have needed a thin-client server for an in-house 3D lab for radiologists to manipulate and rotate images at other workstations. In addition, Mushett’s analysis indicated he would need to hire at least one more technologist. “Like everyone, we’re under budget constraints. Rather than make the investment in technology and people, we decided to look for a different solution,” he says. That solution was to outsource the 3D modeling. 

Mushett’s radiologists read CT exams taken from three different 64-slice scanners and one 4-slice machine. They have plans to install another 64-slice scanner in a third outpatient center. In the last several years, they’ve seen double-digit growth in CT imaging. “We were quickly approaching capacity,” Mushett says. The department opted to outsource the 3D post-processing to 3DR Laboratories in Louisville, Ky., about a year ago.

3DR Laboratories offers a fee schedule for different types of procedures for which it post-processes. “We budget the cost to our operations as an expense, which has provided us with the technology without having a major capital outlay,” Mushett says. “It’s been a break-even situation considering the dollars we would have invested to have the additional technology and full-time employee for our own 3D lab.” Not only does Borgess have access to 24/7 prompt post-processing, it also has seen a further 8 percent increase in CT exams without adding new staff.

3DR Laboratories worked with the radiologists at Borgess to determine which images to send to the DR Systems PACS that has been operational at Borgess for nearly a decade. Referring physicians can access diagnostic images via the PACS, but they cannot manipulate or rotate those images. More and more subspecialists, such as neurosurgeons, neurointerventional radiologists, cardiologists and vascular surgeons, want the ability to manipulate and “spin” images for better pre- and post-operative planning. They also use 3D modeling to help explain pathology and/or surgical plans to patients. These subspecialists are trained and given access to the 3DR Laboratories’ thin-client server, which allows them to manipulate 3D post-possessed images from any personal computer.

A ‘mini-PACS’

At the 260-bed Southeast Missouri Hospital in Cape Girardeau, Mo., referring specialists such as neurosurgeons depend on their access to 3D images for treatment planning, as well as in the OR for intra-operative purposes. The hospital is upgrading its TeraRecon advanced visualization software and licensing agreement so that it can offer unlimited use to anyone simultaneously, according to Radiology Director Tom Welch. Part of the upgrade includes longer storage capacity, up to 16 months of imaging data on the TeraRecon server. Referring physicians gain access to raw data and post-processed images through the TeraRecon server; they do not have to go into the main PACS. In fact, Welch and PACS Administrator Tim Hill say that they are using the TeraRecon server as a mini-PACS, and the increased storage space with the impending upgrade will only serve to emphasize this use further.

Vascular surgeons at Southeast Missouri are ramping up their use of 3D imaging and advanced visualization tools. The group uses these tools to measure aortic aneurysms for graft placement, for example. Welch expects medical oncologists to use advanced visualization tools more and more as the TeraRecon system tweaks its tumor tracking capability to become more robust. The hospital performs about 12 PET/CT scans per week, with that number expected to grow, and the fused images are available to the oncologists through the hospital network. The hospital performs some coronary CT angiograms, and with the upgrade, cardiologists will be able to access and manipulate coronary CTAs through the server, rather than through a dedicated workstation, as is the case currently.

Interestingly, Southeast Missouri collaborated with a neighboring hospital in choosing the TeraRecon platform. Each hospital has a different vendor’s 64-slice scanner and each hospital deliberately did not choose to order the scanner vendor’s post-processing program. “We both bought TeraRecon so the physicians would be using the same tool,” Welch says.

The growing trend clearly is for radiology and IT to make all images available to all referring physicians. The methods as to how hospitals, departments and imaging centers make that happen can vary, from using outsourced 3D post-processing, to access to the main PACS and the post-processed images, to access to a dedicated advanced visualization server that allows users to manipulate raw data. Diagnostic image review is no longer confined to the radiology department. This sharing also seems to improve and strengthen relationships among radiologists and referring physicians, rather than cause turf friction, which was a concern years ago when the ability to share images enterprise-wide began to emerge as a reality. Today, everyone—including patients—benefits from the sharing of 3D images.

Dollars and Sense: Reimbursement for 3D Post-Processing
The Centers for Medicare & Medicaid Services (CMS) considers computer processing to create 3D modeling for MRI or CT studies to be part of the overall procedure and is, therefore, not billable, says Tom Mushett, radiology director at Borgess Medical Center in Kalamazoo, Mich. For non-vascular studies, 3D modeling is billable under CPT codes 76376 and 76377. When the images are processed on an independent workstation , 76377 is the appropriate code.

The majority of cases at Burgess are vascular in nature, so 3D modeling is not much of a revenue stream opportunity for the radiology department. However, the department is beginning to receive more orders from trauma and orthopedic surgeons for 3D and 4D reconstructions, which at this time are billable services, he says.