By Matt Skoufalos
Whether owing to technological improvements, budgetary constraints, improved durability, modular design, or some combination thereof, the life cycles of diagnostic imaging equipment are lengthening. Within the past half-decade, the useful life of workhorse modalities like CT and MR alone have been extended by some two-and-a-half years, according to industry watchers like IMV. As capital purchasing slows due to financial constraints, workflow optimization, and shifting business priorities, device manufacturers, servicers, and the technologists that operate them are starting to reckon with longer-lived imaging gear.
Murat Gungor, senior vice president of diagnostic imaging at Siemens Healthineers North America, attributes this extension of useful life to a number of factors, including more robust device construction, and modular designs that support frequent upgrades rather than total replacement. He also credits comprehensive service contracts and the availability of evergreen replacement components with keeping long-lived diagnostic imaging systems up and running, thanks to environmental and remote monitoring tools that warn of potential problems before they emerge to their fullest extent.
“I think the OEMs started to put much better mechanisms in place, technology-wise and from an IT perspective,” Gungor said. “In the eyes of the buyer, that’s a massive value.”
However, Gungor said he’s also seeing operational and financial choices that are lengthening life spans of imaging equipment; namely, in the wake of the novel coronavirus (COVID-19) pandemic, constrained revenues are contributing to institutional decisions about where to make investments, if at all. Particularly, as growth and demand for outpatient imaging services swell, some health care institutions may hold off upgrades to their legacy locations and assets.
“The financial side of the house is always a tricky thing,” Gungor said, “especially for the last few years. Hospitals many may be in the red; money is definitely an issue. A big health care system may, rather than replacing its existing assets, focus its net purchases on growth locations.”
But he also cautions that a complete system replacement can only be staved off for so long, as legacy imaging systems eventually won’t be able to keep pace with the software and firmware computing upgrades that facilitate the newest imaging protocols and workflow applications.
“There’s a bit of risk-taking in picking the upgrade rather than the replacement route for your legacy assets,” Gungor said. “Depending on your strategy as a health system, you might rather prefer to keep that old MR and buy some of the new components – computers, coils, maybe some AI software on top – a short-term solution to get things going when you invest your real money on other growth initiatives.”
“Some of the upgrades on the systems could become a problem over time unless you completely change the hardware mechanism, and at that point, it becomes a cost-benefit ratio,” he said. “At some point in time, the hardware of the old systems may not be sufficient to handle future upgrades, and those old MR magnets will need to be replaced. At some point in time, older parts won’t be capable of handling patient demand, and the only way to catch up is if you buy brand-new systems and locations.”
Radiologist Michael Recht, the Louis Marx Professor and chair of the department of radiology at NYU Langone Health in New York, New York, said longer-lived diagnostic imaging equipment owes to the cyclical nature of imaging technology itself. In the earlier days of MR, rapid development in the capabilities of newer systems, and the computing power that underpinned them, motivated health care institutions to invest in the latest and greatest devices so as to keep pace with functionality. After years of generational growth, things have leveled off, he said.
“It reached a point where machines got better,” Recht said. “They lasted longer; the iterations were less significant. You could add a package to get more capabilities; you didn’t have to upgrade the gradients because the gradients were really good.”
However, Recht believes the additional image reconstruction capabilities of integrated artificial intelligence (AI), like deep machine learning, are ushering in a new era of generational changes with which legacy diagnostic imaging systems simply won’t be able to keep pace.
“There are periods of time where there’s rapid development, and then you reach a period where things are really stable,” he said. “Then there’s going to be another round of incredible innovation, where the capabilities change, and you’re all going to change again, and it varies from modality to modality.”
“As each modality goes through these innovation cycles, you’re going to need to replace this equipment to maintain state-of-the-art status,” Recht said. “We’re not going to replace the machine just to say we’re replacing the machine. I think we have to judge whether it is increasing our patient care by increasing our diagnostic capability.”
Some purchase upgrades are reflective of specific functions that unlock additional treatment modalities, like cardiac CT, or those that deliver a better end product, like temporal resolution improvements. Other developments support new models of workflow. Recht pointed to the shorter upgrade cycle of ultrasound equipment versus that of CT, as services like point-of-care ultrasound (POCUS) and streaming ultrasound have enabled radiologists to deliver studies at the patient bedside, or read them remotely.
“We have a number of remote radiologists in our group,” he said. “People like to read at home, even the people who are onsite. We use streaming ultrasound to let people watch what’s happening; we do remote breast imaging. It was important to get equipment that could do that.”
Similarly, Recht said, the ability to add AI deep learning image reconstruction to most of the exams done at NYU Langone has dramatically reduced the length of time it takes to conduct them.
“Our knee exams are four minutes and five seconds on average,” he said. “We’re incorporating that into our neuro and body imaging as well. If I’m getting machines that give us a four minute exam, I’m going to certainly upgrade. Techs love it because they don’t have to work as many weekends and nights.”
Recht also points out that other measures that can improve imaging workflow don’t necessarily need to involve wholesale system upgrades. Efficiencies can be derived from improving equipment utilization rates with staffing measures, facility design and intelligent scheduling mechanisms.
“We use dockable tables and prep rooms, so the turnaround time for our patients is two to three minutes at a lot of centers,” Recht said. “You need to get the equipment to do that, but that is absolutely the way to go. We staff our techs much higher compared to most places because we go much faster; we don’t have a lot of techs leaving because they work as a team.”
“I think staffing correctly, using architecture, and working on workflow really converts radiology into a vital resource for the institution, and supports the institution financially,” Recht said. “You just have to run it like any other operation: you have to get involved in scheduling, workflow, and understanding how to make the techs’ jobs easier and the quality more consistent.”
At the University of Texas Medical Branch in Angleton, Texas, Senior Imaging Services Manager Susan Young said that diagnostic imaging equipment purchases are contemplated most often in terms of the existing functionality of the current equipment and the benefit to patients of upgrading. In community hospitals like hers, equipment life cycles extend as far as they can with the aid of improved service support, better staff and organizational leadership.
“There’s always something new that offers something that maybe you don’t have, but you have to step back and say, ‘What are you offering me for this cost that I can’t already do?’ ” Young said. “We have to really weigh the benefit for our patient and for us. If we can keep something working safely with best outcomes for our patients, why don’t we keep what we have?”
“I’m a small hospital in a larger system; we’re all asking for something,” Young said. “Being a smaller hospital, getting what we need here is challenging. There’s nothing in imaging that’s not a large purchase. We want to grow, but there are also much larger hospitals in the system that are growing much faster than we are. Sometimes you have to keep the legacy equipment running because we know another site needs it more.”
Like Recht, Young believes that the equipment life cycle at her facility can be lengthened through proper staff training, workflow optimization, and creating a culture of buy-in from personnel throughout the imaging department. That can happen by involving them in capital purchasing discussions, conversations with vendors and service technicians, and by educating them on the purpose for those conversations. Not only do professionals within a department have a breadth of education that supports the proper functioning of that department, but their frontline experiences can also inform everything within its operations.
“We’re just trying to buy quality equipment, make it last and let our staff feel like they’re part owners of this,” Young said. “If they have a little buy-in from the beginning, it really helps us in the long run to help us keep it up. Give them the information: ‘We have a contract here, and this is what they will and won’t cover.’ When you understand why a leader is asking something from you, I think you’re more understanding and want to do what’s right. And you want to be proud of where you work; proud of what you have.”
Young also noted how that added insight from management especially helps to communicate organizational mission goals in an age of tightening purse strings and rapidly shifting objectives. When service options have been exhausted and organizational leadership has confidence in its site management and the teams they lead, it’s easier for them to support subsequent purchasing strategies.
“Years ago, we just ran through supplies; ran through equipment,” Young said. “Now, having information given to me as a technologist, and as a leader, really helps me get into what we have. For smaller health systems, let’s be proud of what we have. If there’s an issue, call it in, stay on top of it, and eventually, if you’ve shown that you can take care of your equipment, they’ll say, ‘You’ve done everything you can; it’s not that you’ve ignored your problems.’ I keep coming back to letting the team take ownership; letting them know that if it breaks, we have to work to get it fixed.”
The other major factor contributing to lengthening equipment life spans involves the work done by service teams – be they in-house, OEM-contracted, sourced from an independent service organization (ISO), or some combination of all three – to maintain device uptimes.
Matt Forrest, vice president of business development for Renovo Solutions of Irvine, California, said he’s seen hybrid service contracts expand in complexity and scope as capital budgets shrink and manufacturer end-of-life/end-of-support windows close earlier.
“Every hospital that I’m working with is needing to reduce their equipment service spend, and extend the useful life of their current equipment,” Forrest said. “The OEMs are not supporting legacy equipment for as long as they used to; therefore, health systems come to companies like us to support their older and new technology under one comprehensive program.”
Typically, legacy equipment will have more software and cybersecurity vulnerabilities than brand-new equipment would, Forrest said, but these issues can be resolved with specialized tools designed to protect networked medical devices.
“It’s very hard for any radiology department manager to justify replacing several modalities because of software, or because the manufacturer says, ‘These are going to end-of-service,’ ” Forrest said. “We’re seeing that, more and more, there’s a lot of need to support the old imaging systems.”
At the same time, multivendor service contracts, which might include an onsite, in-house response, a regional ISO response, or a remote OEM response, also provide an avenue for third-party companies compiling aspects of each to offer their customers depths of coverage that weren’t previously available.
“We’ve developed relationships with the major manufacturers, so if we don’t have trained resources to service the latest CT, MRI or cath lab, we’ll partner with the OEM to support the equipment on our behalf,” Forrest said. “Parts are not a problem; you can service the latest equipment with the right part from various sources, including the OEM. Software is always going to be a challenge; software is proprietary. But if we need to upgrade software for new functionality on a system, we can work directly with the manufacturer to upgrade as needed.”
“I tell our clients, ‘As long as we can source quality parts, and keep our technicians properly trained, we can help them extend the useful life of their equipment, and that helps reduce total cost of ownership (TCO),’ ” he said. •
