Capital Equipment Track - Amazon Web Services Equipment Track Challenges with New Equipment AcquisiHon Professor of Radiology and Cardiology Johns Hopkins School of Medicine Chief

1/30/16

©DrM.Mahesh–MS,PhD,FAAPM,FACR,FACMP,FSCCTJohnsHopkins [email protected]

1

CapitalEquipmentTrack

ChallengeswithNewEquipmentAcquisiHon

ProfessorofRadiologyandCardiologyJohnsHopkinsSchoolofMedicineChiefPhysicist–JohnsHopkinsHospitalJointAppointment–JohnsHopkinsSchoolofPublicHealth,BalHmore,MD

MahadevappaMahesh,MS,PhD,FAAPM,FACR,FACMP,FSCCT.

email – [email protected] Phone: 410-955-5115 (O)

Disclosure

BookroyalHesfromLippincoOWilliams&Wilkins

1/30/16


2

LearningObjecHves

•  NewequipmentthatisimpacHngclinicalcare•  Outlinemethodstoevaluatenewequipment•  Analyzetrendsinnewequipmentadvancesandpricing

•  DevelopbestpracHcesforprocuringnewequipmentforyourpracHce

CapitalPurchaseProcess

•  Requirements–NeedsAssessment•  SpecificaHons

–  InviHngVendorstosubmitproductsthatmatchesspecificaHons

•  SelecHons–  ReviewingmodaliHesfromvariousvendors

•  PurchaseDecisions–  SelecHngmodality&ensureregulatorycompliance

•  InstallaHonandAcceptanceTest•  ConHnualofQualityAssuranceProcess

1/30/16


3

BestpracHcesforprocuringnewequipment

Needassessment•  PopularityversusNecessity

–  Ex:DigitalmammographywidelyindemandbypaHentgroupsevenbeforeitwasclinicallyproved

–  BreastTomosynthesisaka3DmammographyismorepopularandindemandbypaHentgroups

•  HospitalsmaywishtoacquiringlatestmodaliHestobetheflagshipcentertoaOractmorepaHents

Radiography

X-rayImagingSystems

Bi-planeFluoroscopysystem

CTscanner

1/30/16


4

ImagingModaliHesImpacHngClinicalCare

•  ComputedTomography–  64MDCTvs320orFLASHCT

•  MagneHcResonanceImaging–  OpenvsClosedsystems(1.5Tvs3.0T)

•  FluoroscopyandRadiography –  Flatpaneldetectors

•  MobileandWirelessdigitaldetectors•  DigitalBreastTomosynthesis•  Ultrasound-3DandHandheld

ComputedTomography(CT)

1/30/16


5

16.1 17.2 18.4 19.7 21.6 22.8 25.8

29 33.1

37.9 41.4

44.3 47.2

51

2.2 2.3

2.6 2.9

3.5 3.5

4.8

5.9

6.5

7.5

8.7

9.6

10.4

11

18.3 19.5 21.0

22.6 25.1 26.3

30.6

34.9

39.6

45.4

50.1

53.9

57.6

62.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

0

10

20

30

40

50

60

70

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

To

tal p

roce

du

res

(millio

ns)

No

. o

f p

roce

du

res

(millio

ns)

Out-patient Hospital Total

Annual growth of >10% per year

NumberofCTproceduresinUS

IMVBenchmarkReportsonCT

2007:68.7million2008:73.1million2009:77.5million2010:81.9million2011:85.3million2012:80.6million2013:76.0million

MDCT

CTinMedia2001

2014

RadiaHonBoom,NYHmes

2014

1/30/16


6

CTscanners

•  RapiddevelopmentinCTtechnologyisenabling–  FasterandbeOerCTimaging–  LowerradiaHondose–  QuickassessmentinEDhelpstotriagepaHentstoeitheradmittohospitalorsendhome

•  TwodisHnctsystems–  WidedetectorCTscannersthatcoversenHreorgansinsinglerotaHon

–  DualsourceCTscannersenabledualenergyCTscans

Scancoverage-320vs64sliceMDCT

320 slice

64 slice

MaheshM,MDCTPhysics:TheBasics…,2009 JohnsHopkinsonToshiba320CT

1/30/16


7

DualSourceCT:DefiniHonFLASH*

DefiniHon–FLASH2ndDetectorsetsHllsmallerthan1stbutlargerthanDefiniHon

SFOV:1stdetector–50cm,2nddetector–34cm

X-rayTubeA

X-rayTubeB

DetectorB

DetectorA

*Siemens JohnsHopkins–May2009

Cou

rtesy

of G

erm

an H

eart

Cen

ter/

Mun

ich,

Ger

man

y�

Radiographics2011

DualEnergyCT

•  PromisingnewdevelopmentinCT

•  PotenHaltoimprovelesiondetecHonandcharacterizaHon

1/30/16


8

DualEnergyCTAdvantages•  SoughtamerapplicaHon-

possibleduetotechnologicaladvances

•  ReducesarHfacts•  BeOerdelineaHonof

structures•  EffecHveindifferenHaHng

structures–effecHvediagnosis

Disadvantages•  Costly•  RequiresaddiHonalHme

–  ProcessingImages–  ReviewingImages

•  Notnecessarilysuitableformostsmallertomediumsizehospitals

•  Noextrareimbursement

AdvancedvsConvenHonalCTScannerAdvantages•  Newdetectortechnologies

enableslowerdosestudies•  DualenergyCT,perfusion

studies•  IteraHvereconstrucHon•  ImproveddosemodulaHon•  Structureddosereports

Disadvantages•  Costly•  Notnecessarilysuitablefor

mostsmallertomediumsizehospitals

•  Noextrareimbursement

1/30/16


9

MagneHcResonanceImaging(MRI)

MRIscanners

•  ClosedversusOpenMRIscanners•  Closedsystems–1.5Tvs3T•  OpenMRIsystemstendtobe

–  lowermagneHcfieldstrengths(<1T)–  Imagequalityisomencompromised–  LessinHmidaHngforpaHents–  GreatcomfortforpaHentswhoareclaustrophobic

–  Workswellextremityimaging

1/30/16


10

MRI:3Tvs1.5TscannerCasefor3Tscanner

•  BeOerimagequality•  Fasterstudiespossible•  PosiHoningforfuture

needs•  DifferenHatefrom

compeHtors•  AOractleadingspecialists•  Costly-exceeds$2M•  Reimbursementsaresame

Casefor1.5Tscanner

•  ConvenHonalscanner•  CosteffecHveformost

rouHnestudies•  Lessexpensive-$1-1.5M•  Reimbursementsaresame•  Fieldtrendingtowards

higherfieldstrengths

1.5T3T

MRSafetyChallenges

•  MRsafetyiskey–  Greaterwith3Tduetohigherfieldstrength

•  Definesfacilitydesign•  TrainingofMRusers•  FasterscanimplieshigherpaHentthroughput–higherrevenue

AJR:188,June2007

1/30/16


11

FacilityDesignConsideraHons

•  AssessmentregardinginstallaHonofmodaliHes–  Forex:MRscannerlocatedclosetoelevatorrequiresaddiHonalreinforcementtominimizevibraHons

–  WeightofPET-CTcandictatethelocaHoninafacility

•  RecognizinglocalregulaHonsregardingx-rayfacilitydesignminimizesdelayinconstrucHon–  OmenregulaHonsrequiressubmirngleadshieldingplanspriortoconstrucHon

ScaOerRadiaHon-ImpactonFacilityDesign

8%

0.4%

DataforSiemensFLASH140kVand38.4mmbeamexpressedasuGy/mAs

Console

24&

19&

Console

48&

26&

CTRoom1

CTRoom2

1/30/16


12

PET-CTScanner–FacilityDesign

PET Gantry

CT Gantry

FluoroscopyImageReceptorsFlatPanelDetectors(FPD)vsImageIntensifiers(II)

1/30/16


13

DigitalMammmographyvsTomosynthesis(3D)Tomosynthesis

TomosynthesisSlice

PlanarMammography

DigitalMammogramCourtesy:HologicInc,Bedford,MA

MedicalCenter–VendorAgreement

Desired•  InnovaHon•  CosteffecHvetodeliver•  PaHentcareathigh-quality•  Carewithhighquality•  ProducHvity•  Removebarriers•  AidsinstandardizaHonof

pracHce

Challenges•  Confiningtoavendorcan

limitaccesstobestfeatures/modaliHes

•  AdvancedmodaliHesareuniquewitheachvendor–  ExFluoroscopyorCT

•  Agreementtoworktogetheriseasieronpaperthaninreality

1/30/16


14

MedicalCenterwithSingleVendor

Advantages•  StandardizaHoneasy•  FamiliarityopHmizesuser

training•  EquipmentdownHmecan

beminimizedwithon-Hmeserviceagreements

•  TrainingusersiseffecHve•  CosteffecHvedeals

Disadvantages•  LackofcollaboraHon•  Chancetoseeother

vendorsproductdecreases•  Minimizesexposuretonew

features•  Vendor-userrelaHonship

cansourleadingtosubopHmalservice

MedicalCenterwithMulHpleVendors

Advantages•  Possibilitytoaccessunique

features•  CangetbestmodaliHes

thatfitstheneed•  Abletogetnewandcurng

edgefeatures•  CompeHHonamong

vendorscanbenefitinobtainingbeOerservice

Disadvantages•  Difficulttostandardize

pracHce•  Difficulttocutdealsto

reducecost•  Requirestrainingon

mulHpleplavorms•  Usersmaynotliketoo

manyvariables

1/30/16


15

StandardizaHonvsCustomizaHon

StandardizaHon

•  Assistsinuniformcare–  Ex:StandardheadCTscans

•  MinimizespaHenterrors•  Minimizesbillingerrors•  OpHmizesusertraining

•  Worksbestwithsinglevendor

CustomizaHon

•  Benefittoexplorenewideas

•  Protocolstosuitspecialimagingneeds

•  Exploitsalientfeaturesondifferentvendorplavorms

•  WorksbestwithmulHplevendors

CTDoseCheckStandard

•  CompliancerequiredforCTscannersoperaHnginoutpaHentcentersandphysiciansofficesandnotnecessarilyinhospitals

•  However,salesstaffomenpressurehospitalmanagementtoupgradeCTscannerthatsHllhasmanyyearsofacHvelife

•  NeedtoidenHfykeypersonnel(suchasqualifiedmedicalphysicist)whocanprovidecorrectinterpretaHonofimpendingregulaHons

MaheshM.JACR,2016

1/30/16


16

BestpracHcesforprocuringnewequipment

•  AssemblingrightteamiskeyEspeciallywithadvancedimagingmodaliHes•  ExpertswhoareawareofregulaHons(naHonallyandlocally)pertainingtothesystemsofinterest

•  Requirementswithregardtofacilitydesign,assessingaccreditaHonrequirements,etc.RFcoil

MRIPETA

MRI

PET

BMRI

PET

C

Commonbed

RFcoil

RFcoil

RFcoil

Singlebed

PET PET/CT PET/MR

PET-MRI

1/30/16


17

Conclusions

•  IdenHfyingrightteamwithexperHseiskeyforsuccessfulcapitalacquisiHons

•  AdvancedmodaliHesrequirescustomizedevaluaHoncomparedtostandardizedassessmentmethod

•  MatchingmodaliHestousersneedimprovespaHentcareandcanbecosteffecHve

Contact Info: email – [email protected] Phone: 410-955-5115 (O)

Documents

Capital Equipment Track - Amazon Web Services Equipment Track Challenges with New Equipment AcquisiHon Professor of Radiology and Cardiology Johns Hopkins School of Medicine Chief