Yesterday, Today & Tomorrow: The Evolution of Diagnostic Imaging

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By Matt Skoufalos

As Imaging Support Specialist Chris Bryant was cleaning up some inventory in the biomed shop at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, something gave him pause. It was a Keithley survey meter, one of a number of old pieces of testing gear used in the calibration and maintenance of imaging equipment. It occurred to Bryant that not only had that device seen its day, but that none of his peers even knew what it was or what it had been used for.

“This was stuff I trained on,” Bryant said. “It’s fun to look back and lug around the old tools, but today, there’s a better piece out there that’s a heck of a lot smaller and a lot easier to use.”

For the past seven years, Bryant has focused his career on imaging technology; in the decade prior to that, he was a general biomedical technician. At the outset, Bryant was a general electronics technician. The skills needed for that job were as much mathematical as they were mechanical, which hasn’t changed; what is different now is the degree of efficiency with which many of the formerly complicated procedures have been machine-automated.

“Mechanical knowledge is never going to go away,” Bryant said. “We always have to clean the brakes for the rails, grease the candles for the high-voltage connections; the room does the things it always did. But it’s now a lot more efficient.”

Like his shop, the business of medical imaging has evolved from much more analog processes to automated, computation-driven ones. If Bryant and his team are tasked with micro-level troubleshooting, the solution has become to just replace an entire component instead of wrenching or soldering malfunctioning elements. Similarly, the imaging equipment business as a whole has gone from evaluating the life spans of individual devices to advanced metrics like return on investment (ROI) and total cost of ownership (TCO). At the same time, consolidation in the service provision and replacement parts markets have integrated lines of business that once operated independently, while the devices themselves have grown more complex and reliant on software to expand, automate and unlock the fullness of their potential.

These changes obviate the need for technicians to possess the same degree of mechanical knowhow that Bryant did in his earlier years; ditto the level of computational ability that once was required of people doing the job.

“You used to have to be able to do the formulas to quantify [the repairs],” he said. Now much of that mathematical labor is given over to software, making things easier on repair specialists in some respects while opening up other knowledge gaps that have made it more difficult.

“If you don’t have network training to be able to diagnose where the actual network issue is, you’re so far behind the curve,” Bryant said. “You’re at the mercy of the IT department, or the user. If you can’t definitively communicate to the PACS administrators on their level … if you can’t quantify the issue and say, ‘I checked this and the ball’s in your court,’ then you’re at their mercy.”

“I’ve had to evolve over the process of not knowing very much in the way of networking at all to ‘I’ve got to know this,’ ” he said. “I even picked up a LEED Six Sigma Yellow Belt. It wasn’t required, but to be able to interact with project managers and speak their languages, it was important, for implementation, planning and upgrades.”

Bryant has maintained a thirst for expanding his skill set throughout his career; as they were offered to him, he took on the responsibilities of maintaining laboratory, surgical and pulmonary devices, and when a spot opened up for someone to take on the care of medical imaging equipment, he grew into that as well.

Along the way, the environment at his workplace transitioned as well, merging in 2010 with the U.S. Navy to become a federal health care center, “and things have become a little crazy ever since,” Bryant said. The shift in focus at the facility has increased the amount of patients seen there by a factor of three, and uptime requirements along with them.

That extra workload has intensified the pace of the job, but another thing that’s changed is Bryant’s team. Today, it’s staffed by Navy-trained biomeds, renowned for their level of expertise, reliable work ethic and collaborative spirit. They’ve had two years of 10-hour days in which to hone their skills on a vast array of medical equipment, and their training has taught them to be self-sufficient in the workplace.

“Every single hire in the last five years is a prior service Navy active-duty member,” Bryant said. “One week they’re wearing a uniform, the next they’re in civilian clothes doing the same job. I don’t have to hold their hand when I have a work order.”

In addition to culture change at the tech bench, some of the biggest and most necessary evolutions in medical imaging are being driven in the realm of patient experience. Eric LoMonaco, director of diagnostic and interventional radiology at the Community Hospital of the Monterey Peninsula (CHOMP) at Monterey, California believes that “health care providers have to raise the bar” for patient access and convenience, not only for improved throughput, but also for improved revenues.

“All of us get pressured to improve our patient satisfaction scores, but we had no way of rectifying the situation that’s meaningful in a timely manner,” LoMonaco said.

With Medicare reimbursements tied to the patient satisfaction scores of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, health care facilities need to connect more easily and closely with the people they serve. Typically, they’ve faltered in doing so, in many circumstances owing to the way the institutions ask questions and gather responses. Distributing traditional mailers at CHOMP to patients after they’d seen yielded responses from less than a quarter of patients, mostly because of the process involved.

“Most hospitals use a survey tool post-experience,” LoMonaco said. “Historically, it only used to be snail-mailed, so the response rate used to be really poor. The patient would come in for an MRI, come home, they’d get a survey in the mail, it would get sent to the [data collection] company, and we’d get the report.”

“I was really handcuffed by the fact that when I got the data, the patient had left the building, and most patients were mad that it had taken me six weeks to call them,” he said. Additionally, “the time lapse was so long I could not have a discussion with a staff member [about any issues] with a serious face.”

“We’re still trying to resolve the problem from six weeks ago,” LoMonaco said. “Our patients are communicating at lightning-fast speed. Why aren’t we?”

Instead, CHOMP has had incredible success driving onsite feedback nearly in real-time via a digital survey tool developed specifically for imaging patients. Upon registration, every patient is hand-delivered a VIP card signed by the hospital CEO. The card includes a QR code and a phone number for patients to use to identify any issues. Putting that “skin in the game” led to “almost overnight success,” LoMonaco said.

“We were at a net promoter score of -33 before we started,” he said. “One week after go-live, we hit 100. The second week, 100. The Ritz-Carlton uses this system. Their score is 75. In radiology, we went from the 30th percentile to the 90th and the 100th, and we’ve sustained that level for two years.”

The comment system made it easier for patients to submit feedback on their experiences while in the hospital, instead of after discharge; importantly, it also enabled CHOMP to do something about their complaints. In addition to resolving patient issues, the new system engendered a stronger sense of confidence among leadership that they could guide staff to meaningful improvements based on real issues.

“I don’t have this sense of hopelessness with the staff because the patients are telling us exactly where to spend our time and energy,” LoMonaco said. “Now when I get 99-percent positive feedback every day, in huddle we can pull out the phone and say, ‘The person said you did this or that and it helped so much.’ It’s become this really positive environment.”

“Even when something goes wrong, people own it,” he said. “Maybe tomorrow we do better. Maybe you can reach out for help, let’s put that on the board as something to work toward. It almost gives me purpose to be in the department.”

Expanding the program has also enabled CHOMP to intercept other patient issues before they even arrive at the facility. Once an appointment is booked, patients receive thank-you emails with directions to the location where they’re scheduled, video overviews of the procedures and a phone number to ask any outstanding questions.

Those phone calls are sent to the patient access desk as voice files, allowing staffers to call them back within minutes. Each link in the message is trackable, enabling staff to monitor how many patients are seeking information, and what kind they need – rescheduling or cancelling an appointment, finding out whether they’ve got insurance authorization for a procedure – and offering an opportunity to close that communication gap between patients and the health system.

“I can’t tell you how many patients showed up at the wrong location for a CT or MRI,” LoMonaco said. “It’s really frustrating or disappointing when someone shows up at your desk and is told, ‘I can’t see you today, you’re at the wrong location.’”

“If I get one cancelled CT rescheduled [in advance], that pays for [the cost of the system] in a heartbeat,” he said. “By sending the videos, more patients are less anxious and more prepared. Our no-show rate is at 0.01 percent; nationwide, it’s 5 percent.”

The program has also built fidelity with physicians, LoMonaco said; one radiologist asked to be put on the distribution list so that he could help respond to patient issues over the weekend. He plans to expand the program to help physicians provide feedback about their concerns with the hospital environment as well, because “they’re our customers, too.”

“Hospitals have millions of dollars on the line [in HCAHPS scores] but they say we can’t afford this [type of system],” LoMonaco said. “You’re going to take that loss one way or the other.”

Samir Batra, founder and CEO at the Campbell, California-based BAHA Enterprises believes patient engagement and empowerment are only going to become more critical to the future of imaging, both in terms of how much operational efficiency they engender and the capacity for growth in those lines of business.

“It’s not rocket science to understand what’s happening in health care from a consumer perspective,” Batra said. “If I want to go and spend $5,000, $10,000, I’m going to shop around. I think that experience becomes really, really critical.”

“You already know you’re going to undergo a clinical procedure, but the environment is going to help you have a good experience,” he said. “The better equipped your patient is to understand what’s happening, and the better you’re communicating the value of the information is not only valuable for the imaging department, but the entire ecosystem you belong to.”

Batra believes a handful of factors will continue to influence the expansion of that value proposition, some of them operational and some of them technological. The promise of artificial intelligence and machine learning as applied to imaging studies and personalized medicine has yet to be fully realized; however, the more data sets are fed into algorithms, the more quickly and broadly the knowledge gleaned from their pattern recognition can influence treatment decisions.

“I think the future is going to be more software driven, more machine-learning driven, more data driven,” he said. “Imaging devices are such large, really expensive solutions; the barrier to entry is very large. There’s tons of companies that hit the ground and said, ‘We need to do this,’ but I think their future is still coming.”

Instead, Batra foresees practitioners applying advanced software solutions to more broadly available personalized devices. He believes this same approach also will help manufacturers in the repackaging of their old technologies.

Along the way, Batra believes that the future of medical imaging also will emerge along a collaborative perspective. The most successful institutions realize that staying siloed, however comfortably, means they’ll simply fall behind. It can take them years to catch up. Alternatively, start-ups that have viable products often “need to get bought” to achieve the scale required for market viability, Batra said.

“You’ve got problems of bureaucracy in bigger organizations when small guys can raise a few million dollars and challenge a market,” he said. “Innovation outstrips you now. We’re seeing entrepreneurs from everywhere, and software levels the entire playing field. That’s why the future is going to be in the software side.”

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