Barnes-Jewish Hospital’s Mammography Van from the Mallinckrodt Institute of Radiology.
Everyone expects to find the most advanced medical imaging equipment in high-powered major academic healthcare institutions. But an MRI scanner at a 30-bed, 20-year-old hospital in Morton, Miss., is another matter. Mobile imaging makes it possible.
Thanks to the vision of Country Doctor of the Year 2000, Howard D. Clark, M.D., chief of staff and chief of emergency medicine at Scott Regional Hospital, patients from Morton and five other area hospitals within a 75-mile radius have access to a 1.0 tesla MRI system from GE Medical Systems (GEMS of Waukesha, Wis.) that is motored around in a mobile unit built by Calumet Coaches Inc. (Calumet City, Ill.).
“Most of our hospitals have it two half-days a week,” says Clark. “That gives us pretty good coverage.” The scheduled circuit moves the MRI system about 30 miles at a time. “If any emergency comes up, we can move it to where it needs to be,” Clark adds. “Since I’ve been here, we’ve had two tornadoes.”
Mobile deployment of medical imaging equipment has been available for at least 30 years, driven by the need for advanced diagnostic capabilities throughout this country and internationally. Today, the modalities you’re most likely to see taking to the highways are MRI, PET and mammography, with a few others thrown in too.
Geoffrey Smith, president and CEO of Medical Coaches (Oneonta, N.Y.) describes the cyclic nature of the mobile imaging industry.
“Mobile CT began with hundreds being built in the ’70s and mid ’80s. I would guess there were 300 to 400 built then, but now there are only 30 or 40 built a year,” says Smith. “This is because the cost of CT has gone down, and hospitals realize they need to have a fixed site CT.”
Alliance Imaging’s mobile imaging service
With the necessity of using CT in emergency situations, having a mobile option no longer worked. A similar circumstance occurred with MR scanners with initial construction of about 200 trailers to move this equipment to various sites, followed by a relative decline in numbers. As new uses for position emission tomography are discovered, and reimbursement for procedures increases, the demand for PET scanners is expected to rise.
“Right now, the change we’re seeing in the industry is an increase in mobilization of the newer modalities such as PET and high speed CT,” says Kevin Hoover, vice president of sales and marketing for Calumet. “PET is now a significant part of our business, as well as the rebirth of CT with some of the high-speed applications. The CT business from a new mobile standpoint had really quieted down over the past several years.”
Shifts in the way healthcare is delivered and the way healthcare institutions are operated have helped to drive the mobile imaging industry.
“With hospitals looking to consolidate into hospital groups instead of single site hospitals, people are looking to share capital expenses,” Hoover continues. “Sharing that resource helps to capitalize it more effectively. If you own three or four hospitals, instead of buying one scanner, you can move it from site to site and maximize its use in each location.”
Richard Zehner, chairman and CEO, Alliance Imaging Inc. (Anaheim, Calif.) raises another important issue in favor of utilizing mobile imaging systems.
“Healthcare environments are cash strapped,” Zehner says. “Finding and retaining qualified and highly skilled personnel is becoming more difficult.” A mobile imaging service like Alliance provides qualified staff in tandem with state-of-the-art equipment.
Zehner explains that Alliance’s staff has opportunities to perform large numbers of scans, working with a variety of physicians in different hospitals. “The interchange of information between these employees is far more diverse than they would receive in any given hospital,” he adds.
“Their technologists are all MR certified, and they work really well with us,” says Mike Davis, radiology director, Presbyterian Hospital (Kaufman Texas), an MRI customer of Alliance Imaging. “Because of the equipment they provide, we can schedule people at tighter increments.”
The mobile approach
While the use of mobile imaging services is far from a totally new concept, the opportunity to provide the latest in technology serves as a driving force to the success of this approach to equipment management.
“By working with a company like ours, a hospital has access to the latest generation of technology,” says Paul Crowe, CEO, Mobile PET Systems Inc. (San Diego, Calif.). “We provide access to the state-of-the-art mobile platform, and permanent facilities as well.”
“Our customers contract for our services,” Crowe continues. “They have the technology plus two trained technologists and onboard injections [of a radiopharmaceutical agent]. It is seamless to the community, and the hospital can promote it as their own program.” Mobile PET provides a clinical education specialist to educate referring physicians about the uses for this technology and reimbursement issues.
Robert L. Falk, M.D., director of medical imaging at Jewish Hospital (Louisville, Ky.), agrees that mobile offers flexibility in obtaining a new technology when physician awareness and patient volume could not justify the addition of a new service.
“The advantage to a mobile system is that it decreases your start up costs tremendously, and allows you to wait while you build your market,” says Falk. “Mobile companies are flexible in writing their contracts to fit your anticipated needs. They set it up so that after a certain number of minimum patients per day, the rate they charge goes down.”
Mobile imaging often serves as an interim solution to a specific challenge as well.
“We have used mobile MRI as a bridge to a new magnet,” says Falk. “When volume pushes us to the point where we cannot do everything, there is still construction and purchasing time. The other times we’ve used mobile is over a shorter time when we’re upgrading magnets. If we have a major upgrade that will take our magnet out of service for six to eight weeks, we get mobile in there to maintain volume for the time that our magnet is out.”
If a mobile system is down, everybody loses. Patients are denied the diagnostic tests they require, the hospital that contracted for mobile service loses revenue, and the mobile service provider loses credibility. So the bottom line is utilizing a mobile equipment vendor with high equipment uptime guarantees.
“It must be a partnership between an OEM of medical imaging equipment and the manufacturer of the trailer in which it is placed,” says Smith. “These are extremely complicated units, and one of the most important aspects in the way they’re manufactured is to make sure they’re providing dependable service.”
“I know the machine will be here on time and ready to go,” says Presbyterian Hospitals’ Davis. “When I drive into the parking lot on Thursdays, there it is. The uptime of the machine is over 90 percent for the last year. I think that is exceptional for a machine you put on the road and drive around.”
The trailers are custom designed for this purpose because they carry their expensive loads on roads with potholes, changing outdoor temperatures, and fluctuations in humidity.
“These trailers cost $750,000 with elaborate air handling systems that deal with humidity and temperature, and everything is shock mounted,” says Alliance’s Zehner. “There are generators on board so even when it is moved from site to site, the environment within the trailer is maintained. As it gets to each site, we do daily QC to make sure the image quality matches up to the phantom, so we maintain our reliability.”
Medical Coaches’ Smith echoes the importance of maintaining the internal environment, “In Minnesota, where it gets down to 20 below, they must have a generator that keeps the equipment warm, while having a chiller to maintain a cold jacket around the [MRI] magnet during transport. With PET, the systems have crystals that are sensitive to temperature.”
Once the trailer arrives at its destination, the parking space must be level with ready access to power and phone lines. It also is helpful if it is in close proximity to the hospital or clinic where patients originate. Many institutions provide a corridor to the trailer to minimize patient discomfort.
Zehner cites the importance of a comfortable interior design of the trailer for both patients and technicians. The tile floors, dim lighting, artwork on the walls, appropriate air circulation and music patients can listen to while the MRI is being performed are all important ingredients to creating a comfortable environment. “Other than the size, this is no different from an MRI room inside a hospital,” says Zehner.
But, of course, glitches occasionally occur. Jewish Hospital’s Falk describes that their Mobile PET unit is parked a block and a half from the hospital, thus creating a problem of integrating scan results into the existing PACS.
“We are now 95 percent filmless in our department,” Falk says. “At the current time we cannot put PET scans into our PACS, but we have a separate computer in our reading room. Scans are archived onto our workstation, and we print some selected films as a hardcopy.”
Another essential component to successful operation of a mobile unit involves the education and training of the staff who operate it.
“That includes the person who will be transporting and setting-up the mobile unit to ensure maximum operational uptime,” says Calumet’s Hoover. “Mobiles may be on location for months as interim solutions, or they can be moved between sites every night.”
The top 10 reasons to choose Mobile
1. You’re upgrading to a new piece of equipment and it takes awhile to revamp the space. Don’t lose patients ? use interim mobile solutions.
2. You want to see if patient volume is really there for a new technology. Will physicians use this new technology? Find out before making a gigantic capital outlay for building and equipment.
3. You’ve run out of space in your facility.
4. Your need for imaging equipment outstrips your current fixed imager. You have enough patients to keep your MRI busy nine days a week, and you only have one. Use a mobile for two days a week.
5. You work in a rural setting. There aren’t enough patients to justify an MRI in your facility, but sharing one with other hospitals makes a lot of sense.
6. It’s a great way to advertise your service. Having a giant trailer going down the highway with your hospital’s name plastered on the side builds name recognition.
7. Since many mobile services use equipment from several vendors, you may have the opportunity to try products from different OEMs before making a purchase decision for your permanent equipment.
8. The staff that comes with the mobile equipment are highly trained, experts in their field. Do you have that available in your employee pool?
9. When you purchase very expensive equipment, you can expect to be using that for eight to 10 years. In mobile units, the turnover of equipment is usually much shorter at every three or four years.
10. If you find an excellent service, you’ll have fewer headaches with equipment maintenance, staffing issues, and physician satisfaction with the quality of the images.
Calumet provides service lines that are available 24 hours a day, 7 days a week in the event that something goes wrong. Besides diagnostic functions, disease screening can be done easily with a mobile coach.
Mobile mammography, available since the mid-’80s, performs the critical function of early detection of breast cancer in non-traditional settings. With a Midwest Mobile Technologies Inc. (Cincinnati) van housing their Siemens’ Mammomat system Barnes-Jewish Hospital provides mammography screening to 7,500 women a year.
“We take our van to Schnuck’s grocery store parking lots, and 50 or 60 corporations in the greater metropolitan St. Louis area,” says Betty Hayward, senior coordinator, mammography outreach program at Barnes-Jewish. “Women can have a mammogram in 15 to 20 minutes.”
“We reach a lot of women who would not take the time to go elsewhere,” explains Kate Graham, R.T. (R)(M), the mammographer on the unit. “We do many elderly women and those who otherwise would not have one done.”
Another screening application is being launched within the next six months by a new start up company, MDS Industries Inc. (Huntington Beach, Calif.). With a GEMS’ Light Speed CT scanner in a Calumet Coach and a staff of technologists, they anticipate performing calcium scoring CT scans for corporation employees to detect heart disease at an early and treatable stage. Off-site radiologists and/or cardiologists will read the scans and provide reports.
“In a 30- to 60-second scan, they can determine if you have calcification in the major arteries of your heart or tumors in your upper body,” explains Lloyd Jarvis, CEO of MDS Industries. “We will give every patient a CD of their exam as they leave.”
The CD provides an immediate record. Jarvis describes one case where the patient had undergone a scan, and based on the results, made an appointment with a cardiologist. Before he could keep that appointment, he had a heart attack. The patient’s wife brought the CD of his scan to the emergency room so that personnel could see where the blockage was – which saved considerable time in diagnosis and initiating treatment.
Although mobile imaging presents exciting opportunities, there are challenges in this field as well. Given the climate of managed care, reimbursement issues often arise in this, as in all forms of medical imaging.
“A hospital may charge $900 to $1,000 for an MRI scan, but with their managed-care contract, they are only reimbursed $400,” says Alliance’s Zehner. “Often an urban center is paid less than rural markets.”
PET imaging has its own series of hurdles. Access to the radiopharmaceutical fluorodeoxyglucose (FDG) used in PET imaging may be severely restricted. A single dose of FDG, with a half-life of two hours, may cost between $400 and $500. If the patient does not show up for the scan, and the dose is wasted, recouping those costs may present challenges.
Mobile PET Systems, with a current fleet of 15 mobile PET units across the U.S. and another six to eight anticipated in the first half of this year, recognizes the need for additional FDG production sites.
And with every challenge comes an opportunity. Given the scarcity of FDG, Jewish Hospital’s Falk suggests that they may put in a cyclotron to produce FDG and other agents for their use, and provide radiopharmaceuticals to the other PET scanners in the area.
Arnie Wolfson, director MRI, nuclear medicine/PET and ultrasound at Torrance Memorial Medical Center (Torrance, Calif.) notes how much they have learned about the needs for PET imaging because of their use of Mobile PET Systems services.
“You need an injection room, an observation room, and a dedicated bathroom because of radioactive material,” says Wolfson. “You also need for people to be restful and quiet. If it is a well-lit room with lots of activity, the FDG uptake will show near patients’ eyes. If the person is tense, their muscles will light up because that is where the activity is.”
Mobile imaging is here to stay
With all of the challenges inherent in running an efficient, cost-effective radiology department these days, mobile imaging services provide opportunities to the latest technology with an immediacy not possible in many fixed-equipment locations. With bricks and mortar building space at a premium, the mobile option may just meet your needs.