In radiology, the availability of virtual technology has long been a reality. But questions over effectiveness and reimbursement have hindered widespread adoption of the cutting-edge technology.
While 3-D diagnostic imaging has gained ground among providers, cost and reimbursement issues have hindered wider adoption
It has been roughly three decades since doctors began using virtual imaging—CT, MRI or ultrasound scans converted into three-dimensional images—as a screening, diagnostic and surgical-assist tool, and a growing number of studies are finding the technology to be nearly as effective as more invasive surgical alternatives when it comes to detecting diseases and conditions.
A multicenter study sponsored by the American College of Radiology and published in the Sept. 18, 2008 issue of the New England Journal of Medicine found, for example, that 3-D colonography detected 90% of tumors previously diagnosed using the more invasive colonoscopy method.
A Nov. 27, 2008 study published in the same journal also found that cardiac CT scans—a 3-D imaging technology—were 93% as precise as cardiovascular catheterization in identifying patients with heart blockages and equally as accurate in pinpointing which patients would need to undergo bypass surgery or stenting to treat their heart disease.
While virtual-imaging techniques have so far proved slightly less accurate than conventional screening and diagnostic methods, many providers believe more patients are likely to undergo less-invasive virtual-imaging procedures, allowing for earlier detection and more successful, cost-effective treatment of diseases.
Elliot Fishman, a physician and director of diagnostic imaging and body CT for Johns Hopkins Medicine in Baltimore, says many other studies have found 3-D imaging detection of diseases in the stomach, pancreas and other organs to be 20% to 30% higher than conventional scans.
But despite those findings, standard usage of 3-D imaging has been thwarted by a variety of factors, imaging industry experts say. They include an uncertain reimbursement environment and a lack of uniformity in how providers access and use the technology.
“Reimbursement is very challenging,” says Jason Launders, a medical physicist who evaluates imaging devices for the comparative-effectiveness research organization ECRI Institute, Plymouth Meeting, Pa.
Launders notes that in recent years there has been a reduction in the number of Current Procedural Terminology, or CPT, reimbursement codes that allow providers to bill for time spent constructing a 3-D image from CT, MRI or ultrasound scans.
“There are two codes that cover 3-D reconstruction,” Launder says. “If the referring physician asks for the image in 3-D, then the codes can be used, but the radiologist can't just (construct the image) and be reimbursed for it.”
What's more, there is little consistency among payers regarding which 3-D imaging procedures will be covered and how much reimbursement will be provided.
When asked to pinpoint a trend among private payers in covering 3-D imaging screening, diagnostic and surgical procedures, Susan Pisano, spokeswoman for the industry trade and lobby group America's Health Insurance Plans, says she wasn't able to.
“The policies are ever-evolving,” Pisano says. “I think with all these imaging techniques, from traditional to high-tech, the companies will look at the evidence and the guidelines. It may be that the evidence is more convincing with certain technologies.”
Adding to the uncertainty is that the CMS has issued what some see as inconsistent Medicare coverage policies for 3-D imaging.
In March 2008, for example, the CMS backtracked on plans to limit its coverage of diagnostic cardiac CT scans to patients enrolled in Medicare-approved studies. The agency made its decision despite concluding that current studies haven't shown whether cardiac CT imaging is as effective as traditional angiography in diagnosing coronary blockages.
This past May, the agency issued a seemingly conflicting coverage policy memo on colonography screenings. In that case, the agency decided not to cover the 3-D technology for use in routine colon cancer screenings, saying the evidence was inadequate to conclude virtual colonoscopy was an appropriate screening test for colon cancer.
As a result of such reimbursement issues, providers themselves aren't in agreement on whether to embrace 3-D imaging as a standard technology with significant clinical value or relegate it to an add-on service supplied only at a referring physician's request.
“It's not to a hospital's benefit to do CT colonography even though it's cheaper (than colonoscopy), because it doesn't lead to surgery if the scan is negative, and there's no reimbursement,” says Julia Fielding, a physician and radiology professor and head of the abdominal imaging division at the University of North Carolina.
But beyond reimbursement concerns, expense and a lack of technological uniformity have also slowed adoption of 3-D imaging technology.
Neither the American College of Radiology nor the Medical Imaging & Technology Alliance was able to supply statistics on providers' 3-D technology adoption rates. But industry observers tell Modern Healthcare that most hospitals and imaging centers already have the basic technology needed for performing 3-D imaging studies.
“There is not a machine we sell today that doesn't have 3-D capability,” says Doug Ryan, senior director of the CT business unit for Toshiba Corp., of his company's imaging lines. “Whether we're selling a 16-, 32- or 64-slice scanner, every one of them goes out with 3-D capability.”
But while hospitals and imaging centers are able to take scans that can be converted into a 3-D image, many don't have the expertise needed to make the conversion. “It involves some handwork, so you really need a very skilled technologist to process those images,” Fielding says. “They're usually not the same tech who obtained the images, but they've typically previously done that type of work.”
While her facility, the University of North Carolina, employs a number of 3-D imaging technologists, the cost for such dedicated staff is out of reach for most community hospitals as it would mean adding additional workers, she says.
Even if providers have the expertise, they often are limited in their ability to produce a high volume of 3-D images. “Most hospitals will have only one workstation because it's so expensive,” Fielding says.
Ryan, of Toshiba, concurs. While his company doesn't sell 3-D imaging workstations, it does partner with a softwaremaker to supply complete virtual-imaging technology packages to providers. He notes that workstations typically cost between $100,000 and $150,000 each.
Advocates of 3-D imaging say that despite such challenges they see significant value in the technology and believe it is poised to become a standard part of patient care. They cite three factors: declining costs, the availability of more user-friendly image-conversion software, and growing interest in the technology among physicians outside of the radiology suite.
“In the last five years, all of the companies have developed (3-D) software that sits on a server,” says ECRI's Launders. “You can set up an entire hospital for $200,000 plus an annual licensing fee.”
The newer software, Launders adds, can be downloaded onto a PC and is much more intuitive than older software. It allows cardiologists, surgeons and other doctors who may have a need for more detailed scans of their patients' imaging studies to simply call up an image from a picture archiving and communication system or a disk and automatically convert it into a 3-D view. Once the image is constructed, the software allows the user to rotate the view, change the contrast and even take away bone and other structure to get a more precise view of the area of interest.
Such ease of use is prompting nonradiology specialists and surgeons to use virtual images to get more accurate views of their patients' diseases and conditions and plan for subsequent treatments and surgeries. “Radiologists control this technology at the moment, but I see it as—once the genie is out of the bottle and you see how easy it is—a whole lot of providers will use it,” Launders says.
Letting the genie out of the bottle is precisely what one medical software provider is hoping to accomplish. Earlier this month, Redmond, Wash.-based FiatLux Imaging took a calculated step aimed at making 3-D imaging a ubiquitous tool. The company made its 3-D-image conversion software, FiatLux Visualize, available for free download by any healthcare professional. The software can use MRI or multislice CT data to construct 3-D images.
“What we're trying to do is make 3-D imaging a big pie and drive adoption,” says Tom Sanko, vice president of sales and marketing at FiatLux. “We're artificially constrained right now. Most of the solutions out there are marketed to radiologists, but there are millions of healthcare providers who could use this technology.”
Sanko says his company's hope is to get surgeons, orthopedists and other specialists as frequent users of its 3-D technology. The company plans to make money by creating add-on products that it sells to physicians, Sanko says. He declines to reveal what those products will be.
For Sanko and other advocates, the future of 3-D imaging won't rest on better reimbursement, but on the ability of the technology to become cost-effective and improve workflow and clinical outcomes.
“It has to fit into a physician's current workflow,” Sanko says. “If they have to spend a lot of time training on it, or if they have to make a lot of changes, it won't work.”
But Sanko acknowledges that getting away from the reimbursement question could be tough. “When we were trying to sell the original version of this software, we got a lot of questions from doctors: What's the reimbursement on this? But if that's what you're looking for, this is probably not the right technology.”
Fishman concurs, saying his hospital long ago embraced the use of virtual imaging technology for reasons other than reimbursement.
“Johns Hopkins does more than 200 3-D images a week. A patient would never go to surgery without it. It's become part of workflow and what the surgeons expect.”
The University of North Carolina has a similar philosophy, Fielding says. She notes that while reimbursement for 3-D image processing is minuscule or nonexistent for most types of radiology procedures, her hospital is using the technology for a growing number of purposes, particularly surgical.
“We use it routinely for ultrasounds and most of our vascular work and liver transplants and resections,” Fielding says. “I do think in many places that we use it, the patients get better care, and the surgeon can be more confident about where he or she goes.”
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