Health imaging operations have become increasingly difficult in recent years. 2007 in particular has been a milestone with the reimbursement reductions from the Deficit Reduction Act (DRA) hitting imaging facilities and departments hard. (And further cuts to Medicare, proposed in current legislation, may not be too far behind.) Besides declining reimbursement, external factors such as greater competition and changing regulations are putting additional pressure on already constrained operations in hospitals and freestanding imaging centers of all sizes, according to the findings of our annual Top Trends survey in which 483 imaging and IT professionals offered their viewpoint.
Many respondents tell us they plan to increase procedure volumes to improve the bottom line, but adding procedures carries its own set of challenges. Increasing procedure volumes and skyrocketing slice counts associated with state-of-the-art solutions such as 64-slice and dual source CT and digital mammography force radiologists, IT staffers and techs to cope with more data, more patients and more work. Consequently, improving workflow poses a challenge for all imaging providers. Overall, this year’s trends show that facilities are buying new technologies such as 64-slice CT and increasing procedure volume and bettering workflow, but hiring fewer FTEs.
Imaging, clinical and health IT technologies continue to provide a holy grail for radiology departments, imaging centers and hospitals of all sizes. Survey respondents tell us they are looking to invest in digital acquisition solutions such as digital mammography and CT, especially 64-slice systems; MRI and PET/CT are next on the priority list. The systems offer a way to differentiate a facility or group from its competition and provide high-quality diagnostic imaging. Other priorities include electronic medical records (EMRs), computerized physician order entry (CPOE) and voice recognition. Each promises to bring about essential workflow improvements and patient care enhancements. Read on to learn about the macro and micro details of this year’s Top Trends in Health Imaging & IT survey.
Survey at a glance
In all, some 483 respondents participated in the Top Trends in Health Imaging & IT survey between July 6 and August 20, 2007. Participation also was solicited by the American Healthcare Radiology Administrators (AHRA) of its members. All data were submitted to and analyzed by Health Imaging & IT.
Respondents cut across a wide array of imaging insiders from radiology administrators to PACS administrators, radiologists and technologists, as well as C-level facility leaders such as CEOs and CIOs. More than 400 hospitals participated in the survey with academic medical centers, hospital systems, imaging centers and physician practices rounding out the respondents. Hospital sizes are nearly evenly divided amongst those under 200 beds, 200 to 500 beds and over 500 bed hospitals. Image volume for all respondents varied from under 10,000 annual exams to more than 1,000,000 yearly procedures. Twenty-two percent of respondents completed 50,000 to 100,000 exams in 2006, and another 22 percent completed 100,000 to 200,000 studies last year.
It’s no surprise that budgets are fairly tight on both the IT and imaging sides of the market. IT budgets for 2007 range from under $50,000 to $9 million. Nearly 30 percent of sites expect expenditures to be flat in 2008, but nearly 20 percent expect a 5 to 20 percent increase—and a lucky 13 percent expect a more than 25 percent increase in IT funds. Imaging budgets are concentrated in the $100,000 to $3 million range, and once again, more than one-quarter will see no change in 2008. But 25 percent expect a small increase, and more than 10 percent are counting on a 25 percent or greater increase. This month, a handful of survey sites share their operational and capital priorities with Health Imaging & IT.
Imaging under pressure
It may come as no surprise that nearly three-fourths of sites report increasing procedure volume as a very important priority for 2008 operations. Sites plan to employ a variety of strategies to ramp up volume. The ticket to increased volume, respondents tell us, is the physician referral base, and there are multiple ways to win referrals. Think technology and service differentiation—remote access to clinical images and the EMR, partnerships with physician groups and alliances with hospitals.
The EMR is rapidly becoming an essential across all types of facilities. Sites such as Fox Chase Cancer Center in Philadelphia are transitioning into the EMR. The advantages, says Administrative Manager Joan Keiper, include improved accuracy and tracking capabilities and increased data security. To put EMRs in perspective, National Coordinator for Health IT Robert Kolodner recently said that 11 percent of U.S. hospitals have fully implemented EMRs.
EMR integration is the No. 1 IT focus for Epic Imaging, a busy, full modality imaging center practice in Portland, Ore. “Freestanding facilities need results integration with referring physicians’ EMRs,” explains CIO and Operations Director John Griffith. Instead of investing in its own EMR, the center is working to develop interfaces to integrate with outside EMRs and thus improve service to its referral base.
Advanced visualization is another priority of survey respondents, with CT reconstruction, 3D rendering and cardiac viewing software high on the collective wish list. And thin is in; most sites are eyeing thin-client solutions.
Epic Imaging provides referring physicians with full access to 3D functionality via a web-based PACS with integrated 3D. The center recently expanded its 3D functionality beyond stand-alone workstations and PACS integration, installing colonoscopy visualization software in anticipation of wider acceptance of virtual colonoscopy among referring physicians and patients.
But advanced visualization can bring challenges of its own. Consider for example Partners Healthcare System in Boston. The mega-enterprise is a 3D pioneer and one of Health Imaging & IT’s Top 25 Connected Facilities in 2007. “We need to get the right information to the right people. It’s important to pre-define what data to send to various physician users from 3D groups, radiologists and referring physicians while [providing users] the capacity to dig deeper into the datasets,” says Darren Sack, corporate manager, enterprise medical imaging. Thin-client 3D, says Sack, can save sites tremendous capital outlay, and potentially deliver workflow and patient care benefits if the software can be modified to share the primary essential tools with most 3D users, who don’t require sophisticated post-processing and manipulation features.
Data aren’t the only resource flowing out of imaging. Expect staff and modalities to be on the move, too, as nearly one-fourth of respondents plan to add remote, mobile or outreach clinical services in the coming year.
Each priority translates into more volume, so sites need to effectively handle higher volumes. Staff will be critical. The demand for technologists will remain high as nearly 60 percent of sites plan to hire techs to support increased volumes. Physicians and IT and marketing staff also play key roles in many growth plans. Marketing staff will handle tasks such as educational programs to referring physicians and consumer advertising. A handful of sites plan to turn to other solutions like tech assistants and remote reading services. The lights will be on longer at many sites, too, as more than half of sites tell us they’ll extend weekday operating hours to accommodate more procedures. Fewer than 5 percent of respondents do not plan to add staff.
|To Increase Procedure Volume|
Increased image volumes feed the next priority—improving workflow. Nearly 70 percent of respondents rated improving workflow as a “very important” priority. Most aim to tackle patient scheduling and registration and many plan to focus on physician and tech productivity. Respondents realize improved systems can enhance workflow, so many are considering PACS, EMR and CPOE.
Declining reimbursement puts tremendous pressure on imaging departments and facilities. More than one-fourth of respondents project decreases of up to 15 percent, and another 15 percent expect decreases in the 15 to 25 percent range. One third, however, are cautiously optimistic and project steady reimbursement charges from 2006 to 2007.
Healthcare facilities adopt differing strategies in the face of the DRA; nearly 40 percent claim cuts encourage them to try to work more efficiently by investing in technology designed to increase productivity/efficiency. The radiology department at Concord Hospital in Concord, N.H., plans to follow this strategy. Reimbursement is a significant issue, says Jay Mazurowski, radiology director and immediate past president of the American Healthcare Radiology Administrators (AHRA). The current coping mechanism centers on increasing procedure volume and leveraging technology to improve productivity and workflow. For example, adding a second CT scanner and upgrading from a 40 to 64-slice system should open an additional 75 CT spots monthly at the community hospital. Equally important, says Mazurowski, radiologists can keep up with the volume. Some sites adopt different strategies; one-quarter of survey respondents claim they will delay technology purchases because of DRA cuts.
The Elizabeth Wende Breast Clinic in Rochester, N.Y., is not delaying technology purchases, but the clinic does struggle with maintaining quality in the face of declining reimbursement. “Financial viability is a concern,” says Business Manager Tess Wade. “Our best bet is to limit patients with insurance companies that don’t meet American Cancer Society guidelines, don’t pay or delay payment.”
Other external factors—regulatory issues, including the Healthcare Insurance Portability and Accountability Act (HIPAA) and physician quality and facility reporting requirements—also keep radiology administrators awake at night. Similarly, competition is alive and well, trimming income at more than half of sites. The most common response to increased competition mirrors that of dealing with DRA cuts; 43 percent of sites plan to try to work more efficiently by investing in technology designed to increase productivity/efficiency.
Epic Imaging strives to differentiate itself from its competition, stressing its reputation as an early adopter of digital mammography, PET, 3T MRI and PET/CT. The center plans to add a 0.6T upright MRI to its installed base of six scanners. “MRI competition has increased since the opening of some single modality sites. We were getting calls from spine surgeons who have heard about the benefits of upright MRI at conferences, and we decided to respond,” explains Griffith. Another Epic plan to offset increased competition and decreased reimbursement is a new women’s imaging building. “Women’s imaging has not been hit as hard by DRA as some other areas, and it’s one-third of our volume,” notes Griffith. The new building and additional patient volume could help offset DRA cuts.
|The Effects of Reimbursement|
Modality expenditures—what’s hot
Adding volume often means adding imaging equipment, but not all solutions are created equally. Digital mammography tops the modality acquisition list for more than 25 percent of respondents, followed by CT, MRI and PET/CT (see chart on next page). Concord Hospital, like hundreds of sites across the country, plans to roll out digital mammography in the next year. The hospital will bypass CR mammography in favor of a full-field digital mammography system to maintain simplicity across platforms for radiologists, says Mazurowski. The primary unanswered question relates to specialized workstations and PACS integration. “We’d like to see PACS vendors develop better hanging protocols and software for digital mammography,” notes Mazurowski.
The Elizabeth Wende Breast Clinic will take a different approach as its switches from a hybrid analog-digital site to an all-digital site by the end of the year. The clinic will supplement its current digital deployment with CR mammography. The clinic decided on CR because of its lower acquisition cost and comparable image quality, says Wade.
CT and MRI continue to be hot items—with one-third of sites in the 2008 replacement market for the modalities. “Buying equipment is the easy part; developing workflow is the challenge,” shares Mazurowski. Consider Partners Healthcare, which is in a constant state of refresh, prioritizing purchases according to those that show significant industry advancement, relate to reimbursable services and improve clinical care. A perfect example? 64-slice CT.
Nearly three-fourths of sites that say they are adding, upgrading or replacing CT are in the market for a 64-slice system. Epic Imaging, which operates two 64-slice systems, may consider 256-slice CT when it hits the market, possibly as early as the end of 2007. Sixty-four slice systems also top the PET/CT market, but the next contender is 16-slice hybrids with about 30 percent of buyers shooting for 16-slice PET/CT scanners.
In the MRI market, 1.5T remains a strong contender. Nearly half of those in the market are eyeing 1.5T systems; however, 37 percent are considering the 3T option. Concord Hospital falls into the 3T camp. “We plan to add 3T MRI with a dedicated breast coil and CAD. It will open the door to breast MRI and increase our MRI capacity,” says Mazurowski.
But high tech is high cost. High acquisition costs are keeping some sites out of the modality market. For example, 25 percent of respondents without digital radiography claim they need, but cannot afford, the technology. For non-MRI sites, nearly 20 percent find themselves unable to purchase a scanner, and 15 percent of sites cannot afford digital mammography.
|Ways To Improve Workflow|
The health IT budget
IT is essential to the efficient imaging department. IT solutions that rank high in the 2008 purchase or replacement cycle include enterprise image management, voice recognition and enterprise data storage (to handle that extra image volume). Enterprise image management, which tops the list, is an unaffordable need for nearly 20 percent of sites that do not yet have PACS, according to this year’s survey. Workflow analysis tools, a.k.a. digital dashboards, also are an important consideration for many respondents. Digital dashboards can be a great asset, says Griffith. Epic Imaging plans to look for some dashboard functionality as well as tight PACS integration with its upgrade to a second-generation RIS next year. Other sites, such as Fox Chase Cancer Center, rely on homegrown dashboards to track critical quality measures like biopsy accuracy, interventional procedures and sedation.
Homegrown is a valid solution for other priorities such as CPOE, which ranks in the top three health IT needs. Partners Healthcare System uses an internally developed system with a decision support layer to make sure the enterprise captures appropriate data for reimbursement and to control high-cost radiology exams. Similarly, the radiology department at Concord Hospital, a recent CPOE adopter, plans to focus on developing radiology exam appropriateness criteria and decision support in the entry fields of its vendor CPOE system in 2008.
|Technologies To Be Replaced or Upgraded This Year|
’08 and beyond
As 2008 grows near, there are some certainties in the imaging world. DRA will continue to make life tough, trimming profits and forcing sites to do more with less. Improving workflow has become an absolute mandate in the face of DRA, increased competition and flat budgets. Sites are turning to a variety of technical and operational fixes. Think advanced technology, strong and talented staff, market differentiation and customer service. And keep up the good work!