Ideas in Hospital-Based Imaging

Young Patients Experience Benefits of iMRI
FRG Aims for a New Compromise in Teleradiology
RCG Launches Services to Reduce CT Radiation Exposure

Young Patients Experience Benefits of iMRI

Children’s Healthcare of Atlanta is one of only four pediatric hospitals in the world to house an iMRI unit.

Making a huge difference for children with brain tumors, cysts, and arteriovenous malformations, the intraoperative MRI is changing the way brain surgery is performed at Children’s Healthcare of Atlanta, one of four pediatric hospitals in the world to house the unit.

“The technology is ideal for pediatric patients as it eliminates the need to put children through multiple brain surgeries to remove a tumor when it can now be done in a single surgery,” said Carol Totten, an MRI technologist at the facility. “Follow-up MRI in the department can be very intimidating for a child and often requires sedation, which has risks involved. These risks can be eliminated by doing the iMRI follow-up during surgery.”

Installed in the hospital in September 2007 after 2 years of research and preparation, the iMRI provides real-time images to surgeons in the operating room, enabling them to see whether the entire tumor has been removed and whether they can remove the remaining tumor during the same surgery. As a result, the critical patient does not need to wait until the next day for a follow-up scan.

Explaining the distinctions between MRI and iMRI, Totten noted that the latter is a mobile 1.5 Tesla unit mounted on a ceiling track that moves the magnet over the stationary patient. The table can be maneuvered up, down, or tilted to ensure that the patient remains the isocenter in the magnet, which is controlled by remote control. After 20 to 30 minutes, once the scan is complete, the magnet is moved back into a docking bay between the OR rooms.

Totten also described an extensive checklist of numerous additional steps the iMRI requires in comparison to a routine brain surgery. For example, the room must be “magnetrieved,” and quality control procedures must be followed prior to the surgery. Patients must be adequately screened for metal, and they must be positioned according to the location of the tumor and its location in regard to the MR coil, she said. “Most equipment in the OR is ferrous and not compatible with the magnet,” Totten continued. “As a result, a full instrument count has to be done prior to the start of the surgery and again prior to any MR scanning.” Furthermore, certain equipment must be powered down and placed behind the 5 gauss line. Lights and other equipment must be powered down as well, with the exception of an anesthesiology monitor.

For 2 years, service coordinator and safety nurse Robin Guthrie and lead MR tech Trista Raymer visited sites and wrote various policies, procedures, and checklists in preparation for the implementation of the iMRI, which costs more than $5 million. Totten said all OR and ancillary staff were required to complete training and perform mock cases.

Their hard work paid off on November 2, 2007, when 7-year-old Zachary Link underwent surgery to resect a right occipital tumor. Executed by Dr Roger Hudgins, the hospital’s chief medical officer of neurosciences, the total resection was made possible by an initial iMRI scan that showed residual tumor. Since this first case, 26 surgeries have already been performed, with many more scheduled.

“I definitely think iMRI will become more widely used in the future,” Totten said. “It will improve the accuracy of brain surgeries and as a result improve the prognosis for patients who have been afflicted by brain tumors. Its uses may also extend into other general surgeries that would normally require MRI follow-up scans.”

—Elaine Sanchez

FRG Aims for a New Compromise in Teleradiology

Foundation Radiology Group (FRG), Pittsburgh, and Jefferson Regional Medical Center announced on December 14 the signing of an exclusive 5-year contract under which FRG will become Jefferson’s exclusive provider of diagnostic imaging services. FRG will perform both daytime and nighttime final reads, and also offers disaster recovery and staff augmentation services.

And for those who worry that on-site radiologists might have something to fear from teleradiology groups on the hunt for new revenue streams, FRG offers an interesting compromise.

“The strategy is to use radiology assistants in conjunction with radiologists on the ground at the hospital to do what’s needed there—meetings and face-to-face work,” explained Brandon Chan, MD, chairman and CEO of FRG. “We’ll also ship out to what we call regional bunkers, like the one we have here in Pittsburgh, where we’ll have subspecialists to read during the day and at night when necessary.”

FRG’s first contract, with Jefferson Regional, exemplifies this approach. “We started performing under the terms of the Jefferson contract in August,” said Tim Pisula, FRG’s COO. “We had a gentleman’s agreement with the hospital to keep that quiet for 90 days, because we wanted to make sure they were happy. We displaced a teleradiology company that was doing night reads for them, and we changed the way their billing was done. Their executive team was happy, and we’re really satisfied.”

Pisula emphasizes that FRG’s services are intended to hybridize with, not supplant, on-site radiologists. “When we have hospital contracts, there will always be positions in the hospital,” he said.

“This move comes at a time when the medical center is investing in state-of-the-art imaging equipment,” said Richard Collins, MD, vice president of medical affairs at Jefferson. “With FRG’s expertise reading and interpreting diagnostic images, coupled with our new equipment, we’ll be providing our patients with the most up-to-date, highest quality care. Additionally, enhanced radiology services will help our physicians to be more effective, and will also help us to attract outstanding new physicians to Jefferson.”

So far, the strategy has worked, according to Pisula. “We took a department where the hospital was losing $100,000 a month, and now they are not losing money,” he said. The secret in the sauce is an Emageon PACS coupled with powerful broadband capabilities at the FRG “bunker.” Now smaller hospitals that can’t afford subspecialty radiologists can have subspecialty reports turned around in less than an hour. And FRG ensures that a board-certified radiologist will be ready to perform final reads 24/7, 365 days a year.

“We’re not enamored with 1-year, night read deals,” said Pisula. “We want to have a meaningful long-term relationship with the hospital. This idea of doing a preliminary read is just counterproductive. If you have a board-certified radiologist read the image once, it’s more productive and more beneficial to the patient.”

As the business expands, explains Chan, they will build regional imaging groups, or bunkers, in multiple states. “There’s still personal contact,” he said. “It keeps a local flavor, with scalability and efficiency.” And FRG has a lot to offer its radiologists—the Pittsburgh office boasts a gym, shower facilities, and a movie theater. “We want people to relax and feel like they’re part of a culture,” said Chan.

Next up for FRG? Growing the business via acquisition. The company recently acquired Oryx Medical Services, Roanoke, Va, and is constantly on the lookout for new opportunities.

“We’ve identified a potential $50 million in revenue within the mid-Atlantic area,” said Pisula. “If we can close half that revenue, we’ll be successful. The bottom line is, we have both sides covered. It’s a good offer for hospital administration, but we assimilate the incumbent physician group as well. We can drive profit margins in an area of declining reimbursement rates.”

—Cat Vasko

RCG Launches Services to Reduce CT Radiation Exposure

While radiation from CT has recently become a hot topic, it has been an area of focus for Massachusetts General Hospital’s radiology department for quite some time. For the past 10 years, the group has been working to reduce dose for patients undergoing CT exams.

“Our job as radiologists is to always use the lowest dose possible to achieve a high-quality exam for diagnosis,” said Giles Boland, MD, vice chairman of radiology at MGH. “A decade ago, we as a department took a strategic initiative. We were ahead of the curve.”

Through its wholly owned subsidiary RCG HealthCare Consulting, the hospital has access to a full-service solution called RadPOPS-CT, which assesses current CT exam practices and protocols, develops a baseline radiation exposure profile, and delivers optimized CT protocols that reduce patient radiation dose by an average of 60%, as indicated by pilot testing. Training and support also are provided for radiologists and technologists, and periodic dosage results are monitored to identify further ways to refine the overall process. Now this service is being offered to hospital radiology departments, group practices, and freestanding imaging centers around the globe.

“Done correctly, reducing radiation dosage does not compromise image quality,” Boland said. “Interpretation accuracy is not impacted by the lower amounts of radiation used with optimized protocols. By utilizing RadPOPS-CT, organizations can improve patient safety and reduce unnecessary costs, improving overall health care delivery.”

According to David Charpie, RCG executive director, the benefits of CT were so enormous that doctors naturally turned to them more and more frequently. It has become so easy for physicians to order CT scans that it has become too easy. “The problem is that machines are getting better, quicker, and new technologies are being delivered to market with ever-increasing frequency,” Charpie said. “It’s almost impossible for the average practicing radiologist to keep track of, and handle, all the protocol changes that are needed.”

As a result, the hospital and its consultants began doing research and came up with various algorithms and protocols, which they tailored to the specific patient. They also created binders containing these protocols that users can turn to if they have any questions. “Before we implemented the protocols, we invested in learning the technology, and we had the change in protocols validated by radiologists and referring physicians, who offered their rigorous analysis,” said Dushyant Sahani, MD, who spent time at different sites working with fellow radiologists to determine the lowest, acceptable radiation doses. Furthermore, within its network of seven hospitals, MGH utilizes a propriety software program that assists doctors with the ordering process and informs them on the CT history of each patient. This way, doctors can be made aware of who received a scan and when.

All in all, Boland, Charpie, and Sahani agree that the focus should be on patient care rather than on bringing in the latest and greatest CT scan. They said the profession should listen to what the American College of Radiology has been saying for a long time, which is to reduce radiation dose. “It’s the right thing to do,” Boland said. “We’re here to enhance the health and well-being of patients, whatever position they are in. Anything we do to harm them should be minimized.”

—E. Sanchez