In a field known for its pioneers, Radiology Associates of Tarrant County (RATC), Texas, has long shown a tendency to take the lead. The group was originally established in 1937 by Tom Bond, MD, one of the first radiologists in North Texas, and 64 years later it is among the largest radiology practices in the state. RATC had the first open MRI unit in the county, added teleradiology nearly a decade ago, and is opening its fourth facility with a picture archiving and communications system (PACS) in place. Recently, RATC also made the progressive decision to acquire a mobile positron emission tomography (PET) unit-the first to serve the Fort Worth area.

“Sometimes we need to take the lead and bring new technology when it is not mainstream yet,” says group president Richard Granaghan, MD. “In order to grow, we need to be proactive and look for new modalities, new ideas, and new ways to bring services to patients and referring physicians.”

RATC provides inpatient and outpatient diagnostic radiology and imaging services across Tarrant County, and its 52 radiologists perform a total of 644,000 procedures annually. The group’s full-service facilities include the Pennsylvania Avenue Imaging Center in Fort Worth; the Arlington Medical Plaza office in Arlington; and the most recently opened facility in North Tarrant County. Procedures performed at these three locations include open MRI, computed tomography/spiral CT, nuclear medicine imaging, bone mineral densitometry (DEXA), diagnostic ultrasound, color Doppler vascular imaging, breast sonography, arthrography, fluoroscopy, intravenous pyelography, hysterosalpingography, and sialography. RATC also operates the Hulen facility in Fort Worth, which offers strictly open MRI.

More than half of the group’s radiologists have received additional fellowship training and several have received certificates of added qualifications in neuroradiology, pediatric radiology, and vascular and interventional radiology. The group’s radiologists also have a say in how RATC is managed. Granaghan presides over an executive committee with five other physicians, who are elected at random. The committee is empowered to make capital decisions up to the $50,000 level, while anything above that figure goes to the group as a whole. The board of directors is comprised of all the shareholder physicians, and physicians become partial shareholders after 2 years.


Acquiring a mobile PET unit was a management decision put before the board in early 2000. A RATC physician, Paul Shyn, MD, had attended the Radiological Society of North America (RSNA) meeting in December 1999 and returned with information on the value and efficacy of PET.

“Up until a couple of years ago, all the PET scanners were in major academic centers. The problem was that they were very expensive, and you had to have a cyclotron on-site,” Shyn says. “At RSNA, it was pretty obvious that PET was no longer just experimental. It is clearly ready for clinical use, and has been documented to be a useful tool.”

The shift in Medicare reimbursement for PET scans in selected indications-evaluation of a solitary pulmonary nodule, initial staging of non-small cell lung carcinoma, and staging or restaging of lymphoma, Hodgkin disease, melanoma, or suspected recurrent colorectal carcinoma-confirmed the group’s decision to move ahead with the purchase. A further widening of the indications late last year to include assessment of therapy and the recurrence of disease for all indications further validates this decision. Coverage was also extended to determining which patients with heart disease will benefit from revascularization and for identifying epilepsy patients who will benefit from surgery.

Filmless in Tarrant County

The decision by the Radiology Associates of Tarrant County (RATC) to implement a picture archiving and communications system (PACS) in its newest facility is indicative of the group’s tendency to be ahead of the curve, no matter the cost. Though the benefits of this new technology certainly were weighed against its expense, the group ultimately realized that being cost-effective in this case also would mean falling behind in what it could offer its patients and its referring physicians.

“You see this system in hospitals but not in too many freestanding centers,” says RATC group president Richard Granaghan, MD. “We realize that we are a large group and there is no question that PACS is coming. In fact, for a lot of people it is already here. Going with that technology for the new center brings us inherent advantages that simply outweighed any cost justification.”

The advantages of going filmless include increased efficiency, a reduced or eliminated reliance on film (and its costs), and an expansion in the number of patients that can be seen by a facility. “More patients can be seen with the streamlined system, allowing RATC to strategically compete with other clinics and hospitals,” says Stuart Gardner, president of SG&A Consulting, Arlington, Tex, which has provided economic modeling for clinics and hospitals for 16 years.

RATC chose a vendor that could provide cost-effective delivery of a system that utilized industry standard hardware and a Windows NT operating system. The PACS features an intuitive user interface, key when dealing with different types of study volumes and personnel.

“Not all systems are equal from the standpoint of user interface; not all have the same flexibility to customize per physician,” Gardner says. “It is important to consider what the expansion opportunities are, as well as the ability to be compatible with other hospitals that might use other vendors.”

System Basics

With the exception of mammography, the facility is completely filmless. The PACS utilizes a redundant array of inexpensive disks (RAID) for primary image storage and archiving, which is configured for 18 months. That allows storage space for approximately 37,000 examinations, with future expansion accomplished by adding additional RAID. All current and previous image sets are delivered within seconds and displayed on a digital flat-panel workstation monitor, which reduces the cost of archiving to pennies per megabyte. The capital expenditure for the system was in the $400,000 to $600,000 range, though Granaghan notes that without computed radiography, systems typically run about $150,000 less.

From the radiology information system (RIS), the PACS compiles patient demographics, the date, and the modality to be used. After the images are acquired, the technologist transfers them into the PACS system, where the radiologists review them. The radiologists dictate their diagnosis into a voice-recognition system that is quality-controlled for accuracy and electronically signed off. The report is then made available to the reporting physician electronically or by fax with reference images, and is held in the RIS for long-term storage. The images are retained in the image archive for long-term storage.

“From the time the patient presents to the clinic, PACS reduces the processing time by 10% to 20%,” Gardner says. “A lot of that has to do with the automatic introduction of patient demographics into the imaging device, which also eliminates errors. So you really have an aggregated yield of 1 to 2 minutes per patient. In the course of dealing with high volume, that adds up throughout the day or month so that the radiologists can see more patients and do so more effectively.”

A complement to RATC’s system is that it incorporates a Web-based feature for the distribution of images to the physician community. When further security and technology issues are resolved, all referring physicians can dial into the server and access images and results.

“That is really new in the industry, and the concept was held back by concerns over security, which have now been addressed,” Gardner says. “This is very tightly secured.”

RATC’s long-range plans are to go totally filmless at all its locations, which will require the addition of new software and hardware, as well as an image repository at each location.

“From the purely financial standpoint for the new office, getting a PACS is probably not a wise short-term investment, but it is just as much strategy as it is economics,” Gardner says. “This decision gives us some added efficiency, and will enable us to shift images around ultimately to other sites and subspecialties. This is a tremendous service.”

-Liz Finch

“We developed assumptions about volume, and did an analysis to see if we could break even,” Granaghan says. “This is new to the area so we had a little bit of guesswork.”

In June 2000, the group acquired its mobile unit, which was chosen for its blend of flexibility and quality of service. RATC is the first group in Tarrant County to have PET, though the modality has been available in Dallas for several years. Although the unit is currently parked at the main imaging center in Fort Worth, the group has plans to move the unit to other sites. RATC is in the process of licensing another site in Arlington, where the unit will be located 1 or 2 days each week.

“We have to be ready to respond to market conditions, and we would love to be able to put a fixed site in and then have the mobile as well,” Shyn says.

Although PET is certainly an expensive undertaking, CEO Lynn Elliott, MBA, says financing was not that much of a challenge to RATC because of the group’s strong relationships with local banks.

“We had several financing alternatives, actually,” he says. “At that time, it happened that the capital lease rates offered by [the vendor] were better than the rates through bank financing, so we ended up financing it through [the vendor].”

Shouldering The Investment

The largest part of the investment was the purchase price, and that was an approximately $2 million capital investment, which includes the scanner itself, the coach, and preparation costs for the hot lab and a pad site, as the trailer is too heavy to sit on asphalt. There also were a number of equipment items that had to be purchased for the unit. Shyn says most facilities looking into PET will probably spend $30,000 to $50,000 for the hot lab equipment alone.

“When choosing your equipment, you don’t want to buy equipment inferior to that of your competitors, however,” Shyn suggests. “If you can afford it, buy a dedicated full-ring PET scanner. It really takes advantage of what PET has to offer. There are less expensive systems on the market, but if a competitor comes in with a dedicated PET scanner, you will be left out.”

Shyn strongly recommends that radiologists and nuclear medicine physicians get into PET, even if that means leasing instead of buying a scanner. Leasing also saves smaller groups from working to fill the unit every day.

“If they wait for other companies to bring PET to town, they will find themselves just receiving a professional fee,” he says. “They should strive to bill for their technical and professional fees.”

Shyn advises groups that want to add PET to prepare to work very aggressively to get their license.

“Even with an existing nuclear medicine license, you need an additional one to handle the radiopharmaceuticals used in PET,” he says. “It can be a very involved process, but you have to keep after it and be persistent. I would advise getting that taken care of as soon as possible, or it will delay implementation.”

“Getting licensing took a lot longer than we thought, because it is a relatively new technology in a mobile setting,” Elliott says. “I would advise other groups to start that process as early as possible. This is not a 2-week to 3-week process like getting a nuclear medicine hot lab approved.”

PET necessitates special training, and RATC sent its technologists to study at the Northern California PET Institute, and to the University of California Los Angeles. Granaghan says he would definitely advise that investment, as applications training goes much more smoothly if personnel are already familiar with PET. Shyn adds that if facilities do not spend a lot of effort in their training and quality of operation, they can quickly lose credibility.

“There is a significant learning curve to reading PET scans, and having a small core of physicians committed to extended study is important to having a quality PET program,” Shyn says.

“When you read a PET scan, you cannot read it in a vacuum,” he continues. “You need to correlate the information with CT or MRI images, and that is critical to giving a meaningful interpretation. I have seen experts in PET really struggle with correlation with some of the other imaging tests. Having a background in radiology or general imaging can be advantageous.”

Considering the applications

The bread and butter application for PET is oncology, and it is used primarily for lung cancer, solitary pulmonary nodules, lymphoma, melanoma, colorectal cancer, and also for other cancers like head and neck cancer, thyroid cancer, and sarcomas. Other neurological applications include dementias like Alzheimer’s and seizure evaluations prior to surgery. PET also can be used for cardiac studies. RATC is currently not offering that application because some of the isotopes used for imaging require an on-site cyclotron.

“That may be possible in the future, but we’ll need to see if the demand is there and if it is feasible to get that locally,” Shyn says.

The PET scanner is designed for coincidence imaging, and Shyn says combining the positron decay with coincidence produces images with better anatomic resolution.

“With cancer, adding PET to the imaging workup improves the overall accuracy substantially, which translates into better patient selection for invasive procedures and better treatment decisions in terms of chemotherapy,” he says. “It also can be helpful to the radiation oncologist for radiation therapy planning.”

Another advantage of PET is that in a number of clinical situations, it saves overall health care costs, making it more efficient.

“I always tell my doctors that PET is not perfect, and just like any other test, it has false positives and false negatives,” Shyn says. “But overall, PET adds to our accuracy and so results in a net improvement in decision-making and management.”

During the first week the PET scanner was in operation, physicians saw about two patients per day. That number has grown to three to four patients per day, partially due to RATC’s marketing strategy.

“We did a lot of premarketing 3 months before we put the scanner into operation,” Elliott says. “We did a lot to educate the potential referring population, and it paid dividends to hit the ground running when we finally had the scanner up.”

Marketing Efforts

Though initially the group marketed to oncologists, pulmonologists, and neurologists, Granaghan says it was surprising to see a large number of primary care doctors referring to RATC for its PET services.

“We thought we would have a large majority of our patients from oncology, but that has not proven to be the case,” he says. “I am surmising that, with managed care, primary care physicians have assumed much more of the workups for patients before they refer them.”

The cornerstone of the group’s marketing strategy proved to be physician education.

“We sent out newsletters summarizing what PET is and what it can do, as well as some that address specific applications,” Shyn says. “I give lectures to physician groups in the community, and our marketing representatives have been visiting the doctors’ offices and providing them with brochures and educational materials.

“Clinicians are interested in PET, but they have a lot of questions: ‘What are the indications?’ and ‘What are the appropriate utilizations?’ The more effectively and quickly you get that information out to them, the more referrals you are going to get,” he says.

“We are considered a leader in this area, but we realize that there are always groups ready and willing to take our place,” Granaghan says. “Ultimately, our goal is to always provide superior customer service, and to provide the procedures and studies our referring physicians want.”

Elizabeth Finch is a contributing writer for Decisions in Axis Imaging News.