Global Radiology in Transition
Radiology Departments Worldwide Are Facing an Uphill Struggle
Philipp Grätzel von Grätz, Swati Prasad | 29-11-2016
All over the world, radiological departments are facing an uphill struggle. Patient numbers are on the rise, and so are expectations of both patients and payers, putting physicians and clinical staff under pressure. Yet, eroding healthcare finances make investments in imaging equipment more difficult than ever. Furthermore, qualified experts and well-trained assistants are increasingly hard to come by. What does all that mean for imaging technology? Are CT systems, for example, really addressing these challenges properly?
Photos: Anna Schroll, Arush Mayank
Rising Health Expenditure
The figures are fairly unequivocal: According to the World Health Organization (WHO), total health expenditure worldwide has risen from 8% of GDP in 1995 to around 10% today. This is true of industrialized economies and many emerging market economies alike: In Germany, total health expenditure increased from 9.4% to 11.3%. In China, it went up from 3.5% to 5.5%. And in the U.S. it shot up from 13.1% to 17.1%.
National healthcare systems increasingly struggle to keep costs in check. Some try to centralize; others do the opposite. Some create artificial price limits on drugs or exclude certain imaging modalities from reimbursement. Others introduce new reimbursement models that reward patient satisfaction or medical outcome rather than the number of interventions or examinations. In the U.S., for example, Medicare will soon base 2% of its reimbursement on outcome and patient satisfaction.
How to keep up with investments needs?
Whatever the national policy is, for healthcare institutions the challenges look remarkably similar all over the globe. While keeping an eye on costs and reimbursements, many have to invest heavily in modern medical equipment in order to cope with rising numbers of patients or provide access to cutting-edge care.
In India, for example, with a demography that is skewed toward the young, hospitals will have to provide up to 700,000 additional beds over the next five to six years, according to projections by the India Brand Equity Foundation, a government trust established by the Indian Ministry of Commerce and Industry. This translates into estimated additional investments of 25 to 30 billion U.S. dollars. In Germany, the number of hospital beds is shrinking while the population ages. There, too, hospitals have to invest to maintain the high standards that patients expect. The German Hospital Federation (abbreviated in German to DKG) estimates that the investment gap in the hospital sector amounts to 12 billion euro, rising by 2.5 billion euro annually.
Radiology at the epicenter
As a discipline that requires significant investments and a high degree of expert knowledge, radiology is at the epicenter of the seismic shifts that are reshaping modern healthcare. To address the shortage of qualified labor, new players are emerging, and teleradiology is on the rise. Take India, for example: Imaging centers in the metropolitan areas are mushrooming. They regularly produce CT reports for hospitals in smaller cities now where trained radiologists and radiology assistants are in short supply.
On a different level, we find a comparable picture in highly developed economies. Integrated Delivery Networks (IDNs) have established themselves as a new model of diagnostic imaging in the U.S., with a hub in the center that provides most of the manpower and expertise for cooperating institutions at the periphery. In a very similar approach, German university hospitals increasingly cover radiological services for small- and mediumsized hospitals in the vicinity.
Working together for a better outcome
Given this background, the question arises as to whether currently available CT systems are suitable for the new realities. Is high-quality computed tomography affordable enough to satisfy the needs of, say, an IDN in the U.S., a regional hospital in Germany or a rural medical center in India? Is the usability of the machines such that they can easily be operated by specialists and non-specialists alike?
Siemens has asked those who are in the know. About 500 radiologists, radiology assistants, chief financial officers, patients, and referring doctors from various countries were interviewed. Of these, 32 even worked together with Siemens representatives over a period of two weeks in a co-creation space on better workflows and improved device features using Styrofoam models brought to life by human creativity. The result is a new CT platform that provides high quality standards but also takes into account the challenges of radiologists all over the world. Hear from some of these people in the following.
Facts & Figures
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- GO technologies is an holistic set of features to support users in workflows beyond the scan itself. They include Scan&GO, an advanced tablet app which allows control of scans from wherever the user is.
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- Thanks to gantry-integrated computers, investment in a separate control room is no longer needed. Valuable space can be saved by having scanner and workstation in one single room.
2 p.m. (CET), Erlangen, Germany
Radiologists at University Hospital Erlangen are struggling to meet the growing expectations of colleagues, patients, and hospital management simultaneously. Yet, compromising on quality or radiation dose is not an option. It is an average day for Professor Michael Uder of University Hospital Erlangen, Germany. The head of the Institute of Radiology attended a major interdisciplinary tumor board in the morning in which he discussed cancer patients with colleagues from surgery, oncology, and other disciplines. Later on, there were two interventional therapies planned. In between this, he looked at recent images, cleared dozens of reports, and dropped in on two other interdisciplinary rounds, before taking the time for our brief interview: “Colleagues really expect us to be present these days. In a modern hospital, radiologists are the only true general practitioners. This is what makes us so important.” Importance has its price, however: Rounds and boards are time-consuming: “All in all, we are talking about more than 30 interdisciplinary meetings per week,” says Uder. A steep increase in interventional therapies has added to the workload in recent years. And the number of diagnostic patients has not decreased either: “Today, we care for twice as many patients as we did a decade ago.” Most need simple examinations, for example head CT scans to exclude bleedings. Others require more complex types of imaging, such as cardiac CT examinations, CT angiographies.
Patient satisfaction: It’s all about radiology
Radiologists have to meet not only the expectations of their colleagues, but also those of hospital management and, most importantly, patients. “In certain areas, patients are beginning to handpick their radiologists, for example in urology and gynecology. Some even suggest examinations themselves,” says Uder. Patients are also becoming more willing to share their experiences – for better or worse. In Germany, reimbursement does not actually depend on patient satisfaction, but in reality it does. If a patient is not satisfied with his hospital stay, he may not come back, and he might even write an unfavorable review online that damages the reputation of the institution. Although patient satisfaction is not just about radiology, the radiology experience is an important part of the puzzle: “A patient who has to wait for three hours for a CT scan will always feel that his hospital stay was negative.”
So how can we make patients feel better? Waiting times, obviously, need to be addressed: “We need to know exactly in advance what examination is needed. More workflow automation would be extremely helpful, too, and also more automatic quality checks to avoid errors.” Matthias May, MD, a colleague of Uder’s in Erlangen, points out another aspect: “When patients get a CT examination today, they often have the impression that the radiologist or the radiology assistant is hiding from them. The reason is that staff has to go back and forth between control room and examination room in order to run the examination.” May is convinced that a modern, mobile operational concept could address this issue: “If a patient feels that someone is close by, it is perceived as better care. It is hard to measure, but it will make a difference.”
Attractive conditions, durable equipment
Hospital management is interested not only in patient satisfaction but also in costs. Radiology, after all, is one of the largest cost factors in a modern hospital. According to Uder, the cost pressure on radiology has risen quite significantly: “Most of it comes not from hospital management but rather from the heads of the clinical departments. Thanks to internal cost allocation, they have to pay us for our service, and we are regularly their highest expense factor.” The Erlangen radiologists see several options to make the total costs of CT systems for a hospital more affordable and more predictable. One important factor, according to May, is durability: “Obviously, maintaining a CT scanner is expensive. But also whenever a CT scanner needs to be repaired, we cannot use it.
If we had a CT system with durable components and less downtime, we would benefit twofold – from lower running costs and reduced downtime. And I am also convinced that nowadays there are certainly ways to monitor the scanners to identify potential future issues or even to perform software upgrades remotely.” Different service models might also help to better calculate costs. Uder likes the idea of having longer guarantees with as many years of service included in the initial payment as possible: “In Germany at least, there are still ways to find funding for necessary investments. But I cannot source any money for follow-up costs. I have to pass these down directly to my customers. Having less follow-up costs would make life easier for us.”
Another cost factor that is often overlooked is investments in rooms and buildings. Uder recalls the purchase of a CT system some years ago that came along with construction costs of almost 400,000 euros. For small- and medium-sized institutions, building costs such as these can be an insurmountable obstacle. University Hospital Erlangen performs radiology services for five smaller hospitals in the vicinity. Uder would prefer to run a CT scanner on site. “But we haven’t been able to find a suitable room that would allow us to install a CT system at reasonable costs.” Conventional CT platforms are not adaptable enough to different architectural realities, Uder emphasizes: “I’d love to be far more flexible with my machines. I want to be able to put them where I need them and not where the building requires me to put them.” One imaginable scenario that could be very helpful for Uder and May, in particular in the satellite hospitals of hub-and-spoke imaging networks, is a standard X-ray-like CT setup: “If there were a remote control for the scanner, and all necessary technology, including basic postprocessing capabilities, were integrated, we would no longer need two or three rooms for a CT scanner. A lead glass niche within the scanner room to protect staff from radiation would be enough,” says May.
No compromise on quality or low radiation dose
Uder and May have various ideas that could help to keep costs of new CT machines in check for radiology departments. What both radiologists would not accept, however, is low image quality or higher-than-necessary radiation dose: “We would not want to compromise either on quality or on low radiation dose. It is obvious that we cannot expect the same tube capabilities in a smaller CT scanner as in a high-end scanner. But we can expect a highly reliable tube, and we certainly expect the dose reduction technologies that have been introduced in recent years,” emphasizes Michael Uder. Matthias May agrees absolutely. Up-to-date iterative reconstruction capabilities to reduce radiation dose is among the first things that come to mind: “We would not want to do without this. Even a small scanner can easily be furnished with it. To provide low-dose imaging, we would also want to have the option to individualize the X-ray spectra. We need tube current modulation, low kV imaging, and we need tin filters for spectral shaping.”
Workflow automation to manage complexity
Perhaps the most pressing issue in modern CT radiology is its increasing complexity: “Handling a CT is almost as complex as handling an MRI these days,” says May. What is needed, he argues, is a design turnaround that puts workflows back into the focus of developers. “This is a real issue even at an university hospital. We have radiological assistants who refuse to work with certain kinds of scanners because they consider them too complicated.” Over-boarding complexity might be no more than a nuisance in university hospitals. In small- and medium-sized hospitals, in hub-and-spoke scenarios, and in integrated (tele)radiology delivery networks, it is intolerable. If a shift has to be staffed with someone less experienced, they might not get the protocol right. The result is suboptimal image quality or a higher-than necessary radiation dose, or both. May’s wish list for a modern scanner thus features a high degree of workflow automation, including clinical intelligence to recognize mistakes and issue an alert if a patient is not suitable for the standardized workflow: “For the vast majority of examinations, standard protocols can be used, and postprocessing can be automatized, including low-dose examinations such as lung cancer screening. These protocols should be available with a click or two. But it must still be possible to go deeper if necessary. Ideally, we have two layers of operation: a simple userinterface, for example on a tablet PC, plus a conventional access that allows us to modulate the standards if necessary.”
Ultimately, the patient benefits
Easy-to-use, standardized workflows make daily routines more efficient. They facilitate disseminated care scenarios, reduce the need of training and make a radiological department less dependent on highly skilled individuals. But ultimately, it is the patient who benefits most from automation and clinical intelligence, says Uder. His example is that of a nightshift examination, when contrast media is often injected by some doctor on duty, who does that only occasionally. There might also be a radiological assistant without enough experience to recognize when contrast media doesn’t flow properly. In the worst case, the mistake is only noticed once the images are ready, and the examination has to be repeated. “In such a case, I would want to have a red warning light so that the protocol can be stopped early.”
2 a.m. (IST), Madurai, India
K. G. Srinivasan, MD, Managing Director of KGS Scan Centre in Madurai, has overcome many challenges that confront radiology centers worldwide with his unique model of focusing on volumes and working round-the-clock.
It is 2 a.m., and Madurai is buzzing with activity. No wonder they call it “Thoonga Nagaram” – Tamil for a city that never sleeps. K.G. Srinivasan, 48, managing director of the immensely popular KGS Scan Center, has emulated this quality of Madurai. Srinivasan, however, prefers to be known as senior radiologist.
“God is the owner of KGS, not me,” he says. Some kind of divine intervention seems to be at play here at this scan center, which is just four kilometers away from the famous Meenakshi Amman Temple. For, it takes on the extraordinary task of working every single day of the year. You will find Srinivasan here, from 10 a.m. to 2 a.m., at his desk – examining scans sent seamlessly to his computer screen from four centers – two in Madurai, one in Ramnad (113 km from Madurai) and another in Arupukkottai (50 km from Madurai). Simultaneously, he is on the phone, speaking to clinicians spread across a 150 km radius around Madurai discussing the scans, even as patients and their relatives surround him, waiting for him to pronounce his diagnosis. “We are a one-stop shop for diagnostics,” says Srinivasan, whose centers have X-ray, CT, MR, and ultrasound facilities. For the sake of proper diagnosis, his team often scans other parts of a patient’s body if the recommended scan provides inconclusive results. All this, at no extra cost.
Leveraging volumes to overcome challenges
The challenges Srinivasan’s scan centers face are no different from those faced by radiology departments across the world. Yet, he has found a mechanism to cope with most of them. Since the center’s inception in 2002, Srinivasan has focused on volumes to recover the steep investments in equipment – the Madurai centers perform 120 CT and 120 MR scans in a day. On peak days, CT scan numbers can even go up to 170, as they did six months back. Srinivasan manages the high maintenance cost of machines by opting for a comprehensive warranty scheme. Equipment downtime is kept to a bare minimum as a supplier’s engineer is stationed at the Madurai center to repair breakdowns.
Similarly, the challenge of postprocessing is taken care of by sending senior technicians to centers in Ramnad and Arupukkottai. “Our core team has remained the same for 15 years,” he adds. It comprises of five radiologists, ten technicians, and four senior nurses. The experience the team has gained over the years is unmatched. The center has addressed the challenge of radiation dose by choosing Siemens’ CARE (Combined Applications to Reduce Exposure) package. And since the quality of power supplied by the government is poor, an uninterrupted power supply (UPS) system, coupled with a generator, ensures the equipment works seamlessly.
Offering better quality at the same price
Volumes have also helped Srinivasan keep the prices unchanged for the last decade. And that’s important since the penetration of health insurance is abysmally low in India. According to the World Bank, out of pocket expenses for India stood at 86% in 2012. All patients who come to the KGS center pay out of pocket. For the poor, the center also does scans for free. Thanks to volumes, Srinivasan is also able to upgrade the equipment every three to five years. These periodic upgrades have led to better quality scans. For CT imaging, the Madurai centers currently have a 128-slice and a 16-slice scanner, while Ramnad has a 32-slice scanner and Arupukkottai has a 16-slice. Recruiting new radiologists has been problematic as not enough of them are able to undertake complex CT protocols.
Therefore, Srinivasan takes them on himself, after midnight. The real issue, however, continues to be accessibility. It is difficult to find radiologists in rural India. Srinivasan is addressing this through technology. Experienced technicians are sent to Ramnad and Arupukkottai, who message or email images to radiologists in Madurai for diagnosis. Over the next six months, Srinivasan plans to open another center in Sivakasi – a town 78 km away from Madurai, known for its fire-cracker and match industries. It is also his birth town.
Replicating the KGS model
Srinivasan is part of an industry that is growing at over 17% per year.1 Yet, approximately one million Indians die each year due to inadequate healthcare facilities.1 Therefore, the scope of replicating the KGS model is tremendous. For instance, the center has a unique workflow strategy whereby they line up three patients to reduce the time in between patients. When one patient is inside the gantry, the second is waiting outside, while the third is being prepared – a strategy other centers could easily replicate. In August this year, KGS organized a conference on mini musculoskeletal review, which was attended by radiologists from across India. Several radiologists were keen to understand Srinivasan’s model. Since then, a scan center in Amritsar has even managed to increase throughput. When it comes to the KGS Scan Center, Srinivasan does not want to spread himself too thin. “In two years, I will be 50. I am not sure if I can continue to work such long hours,” he says. He has the support of his team and family, however, who help him out with accounts and management, it is unrealistic to look for radiologists that match his passion for diagnosis. Therefore, a new CT platform that can address the challenges faced by the radiology industry worldwide is vital.
About the Author
Philipp Grätzel von Grätz is a medical doctor turned freelance writer and book author based in Berlin, Germany. His focus is on biomedicine, medical technology, health IT, and health policy.
Swati Prasad is a freelance business journalist based in Delhi. She reports from India for several publications overseas and has worked as a correspondent and editor for The Economic Times, Business Standard, The Indian Express, and Business Today.
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1India Brand Equity Foundation, http://www.ibef.org
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