Feature | November 10, 2010 | Heather A. Brown, Ph.D.

Covering all the bases is key when implementing 3-D

The turn of the century has brought disruptive technological changes to the medical industry. 3-D/4-D advanced visualization offered cutting-edge technology that introduced a new dimension of glitz to the radiology department. No hospital purchased a 64-slice computed tomography (CT) scanner without a 3-D workstation included.

However, many institutions have learned that a successful 3-D program — one that offers an edge on the competition — requires more than installing 3-D software in the CT department. In fact, many of those very promising 3-D workstations now collect dust in the corner as they sit unused, for many reasons. This article will outline a framework for imaging directors to consider as they utilize the exciting technology of advanced visualization to their department’s benefit.

Enterprise is a Must
Some radiologists minimize the use of 3-D imaging, because they are trained to examine 2-D images and reconstruct 3-D images in their minds. While studies show that 3-D visualization improves diagnosis, many successful 3-D programs are geared more towards the referring physician than the radiologist.

Clinicians greatly appreciate post-processed images that reveal critical findings in an intuitive view. For example, a 3-D rendering can show the proximity of blood vessels to a tumor, a complex fracture or the degree of stenosis for treatment decision-making. Appropriately rendered 3-D images can change a surgeon’s approach to a complicated procedure and can even decrease surgical times and improve patient outcomes. Furthermore, clinicians frequently review 3-D images with patients because they provide an educational tool.

Successful 3-D imaging programs serve numerous end-users, including radiologists, cardiologists, orthopedists and more. Radiologists will want access from their reading station; a surgeon may want access from the operating room (OR) and a cardiologist may need to read a case remotely.

Delivery of the appropriate images begins with a flexible architecture that can accommodate many levels of use, both inside and outside the institution. A dedicated workstation offers little in the sense of efficiency. Some vendors have tried to retrofit workstations with remote log-in tools, such as Citrix or add-on client/server components. But a true unified client/server system allows designated users to access and manipulate data easily and efficiently as necessary to maintain the patient’s continuum of care.

A director planning the implementation of a 3-D program not only has to consider what software they purchase, but also who has access. Scalability is a critical aspect of any enterprise system. Client/server systems are based on a centralized processing server with multiple access points. Either the number of concurrent users or number of slices loaded becomes a limiting factor.

Depending on the architecture of the system, hardware might have to be purchased for each concurrent user. Directors investigating enterprise systems should understand the hardware architecture, proprietary nature of the hardware, associated maintenance and licensing costs, and bandwidth constraints for remote access.

Lastly, a truly virtual system should offer the ability to share a session so that multiple users can log in simultaneously to view and interact with a case. With Web-sharing capability, which requires no client software to be installed, clinicians can get a quick consult with a radiologist when they can’t physically go to the radiology department. This improved communication and access to radiology allows both physicians to better understand the case and ultimately improves patient outcomes. Other areas of collaboration include tumor boards, acute stroke decision-making and endovascular presurgical planning.

Workflow Issue
With the appropriate software system in place, multiple levels of interaction will occur, including basic viewing to more advanced usage. The most common model for a 3-D program is to have technologist super-users — either in the computed tomography (CT) department or a centralized 3-D lab — perform initial post-processing. They can save a series of images to the picture archiving and communications system (PACS) and/or save the processed case in the system so any physician can resume workflow to maximize efficiency.

History has proven 3-D software alone does not create a successful advanced visualization program. As this cutting-edge technology stormed into imaging departments promising amazing multicolored, dynamic anatomical renderings, users quickly found it takes time to learn how to use the tools and become proficient.

Training is a critical step in establishing a program; basic vendor applications training will not be enough. Technologists need to understand the anatomy, pathology and processing tools they are using to generate each image. Without a champion physician who is willing to act as a resource, the techs will be left on their own to create what they think may be useful.

Both the physician and the technologist have to be committed to working together, especially in the beginning. Directors should look for services that help align what the physicians need and then teach the technologists how to generate the images.

Establishing post-processing protocols is essential for a technologist-driven 3-D program. By having protocols for specific types of cases, technologists know exactly what to produce (maximum-intensity projections [MIPs], curved vessel views and 3-D rotations), and physicians can rely on receiving a consistent set of images every time. Protocols can also be tailored to support referring physicians.

A system that can be customized with user-defined protocols will help drive consistency and quality. User-defined palettes can align the most frequently used tools for streamlined workflow. Macros can assemble commonly used sequences of functions into a single button click. A single “one-size-fits-all” interface will not meet the multitude of needs placed on an enterprise system; a flexible interface can be adapted for many different users and study types.

Budgeting for 3-D Capital Expenditure
Imaging directors immediately begin a return-on-investment (ROI) analysis when they hear the term “capital expense.” The majority of 3-D visualization is for computed tomography angiography (CTA) exams where the post-processing is bundled in the Medicare current procedural terminology (CPT) code. Therefore, directors should consider other factors in their justification for 3-D software. Can the capital expenditure be offset by increased scanner throughput, consolidation of disparate software systems and increased program success? Are other financial models available?

- Increased scanner throughput — With 6,000 CT scanners in the United States, nearly every medium- to large-size hospital now has a 64-slice CT scanner offering CTA exams. Referring physicians may develop loyalty to a specific institution if they can depend on state-of-the-art 3-D images that assist them in their patient care (e.g., presurgical planning, post-treatment surveillance, patient education).

While 3-D processing for vascular imaging is not reimbursable, departments make money on increased throughput with improving physician loyalty. High quality and efficient delivery of 3-D imaging may influence where clinicians send patients for imaging.

The vast majority of advanced visualization performed does not get reimbursed directly, but is instead a required component of the bundled CTA charge. (See section below on 3-D reimbursements.) However, there is a CPT code for nonvascular exams that can earn substantial reimbursement. The CPT code, 76377, reimburses approximately $100 per case above and beyond the reimbursement for the scan.

This is most frequently used on orthopedic CT exams. An orthopedic surgeon may greatly appreciate a 3-D reconstruction of a comminuted fracture for presurgical planning. By marketing 3-D services for nonvascular exams, imaging centers may benefit from both increased scan volumes and 3-D reimbursement.

- Consolidation of software — Directors of radiology are faced with ongoing maintenance and upgrade costs of numerous software platforms across multiple modalities. These computers are often scattered throughout the department or hospital, creating disparate islands of information, causing bottlenecks in workflow and forcing doctors to move from one computer to another to access a single patient’s data.

Directors should take an inventory of their current software products. The price of upgrading to an all-encompassing enterprise-wide software system can be offset by the reduction in annual maintenance costs of the systems it replaces. The ideal software solution should be vendor-neutral, multimodality and application-rich.

- Increased program success — Hospitals garner recognition from services such as stroke, trauma and cardiovascular programs. In order for these programs to be successful, the right people have to access the right data at the right time. For example, CT perfusion imaging is required to support level 1 stroke programs. This may be one of the most challenging to implement.

The decision-making process on whether to use tissue plasminogen activator (tPA) treatment is often multitiered, requiring more than one physician to access and interpret the data in a matter of minutes. Knowing that every second counts for the stroke patient, these programs must have a defined workflow with easily accessible software to meet the demands of extreme high-speed turnaround.

- Purchasing an enterprise solution with no capital — A major barrier to purchasing an enterprise software system is the capital expenditure and recurring software maintenance costs. By exploring leasing, “software as a service” and other payment options, the cost of 3-D software can be transferred to the operational budget where it is more easily justified.

In the current economic climate, many institutions have constrained budgets with capital freezes, seemingly eliminating the opportunity to upgrade to an enterprise solution. Software companies have begun circumventing a lack of capital with more flexible budgeting options. Financially-savvy directors should explore all cost models in their preliminary investigation of software vendors.

Many factors play into the success of a 3-D program. Directors should:

- Set goals for 3-D service, such as establishing new programs (e.g., cardiac) or increasing physician loyalty.

- Be proactive in selecting their software systems and not simply accept the cost of the workstation when they purchase major equipment.

- Take inventory of the existing software systems and evaluate which can be consolidated with an enterprise system.

- Designate both technologist and physician champions to establish protocols and workflow that will meet the goals of the 3-D program.

- Budget for and establish a training plan for the technologists who will be performing the majority of the post-processing.

- Create a marketing plan to promote 3-D services to clinicians.

Cracking the Codes for Reimbursement
Reimbursement for post-processing is dependent on the type of CT or magnetic resonance (MR) scan involved. Any CT angiography (CTA) or MRA scan requires that image post-processing be performed as described in the Medicare current procedural terminology (CPT) codes (see example 70498 below). For non-CTA/MRA exams, 3-D post-processing may be reimbursed independently from the scan itself (see 76377 below).

Proper documentation for reimbursement of 76377 includes:
1. written order for the referring physician for 3-D processing; or
2. radiologist dictates that 3-D was necessary for interpretation of the exam.

- 70498 CT Angiography, Neck – CTA, neck, with contrast material(s), including noncontrast images, if performed, and image post-processing.

- 76377 3-D Rendering with Post-Process – 3-D rendering with interpretation and reporting of CT, MRI, ultrasound or other tomographic modality, requiring image post-processing on an independent workstation.

Heather A. Brown, Ph.D., assistant professor at Jefferson Community and Technical College, Louisville, Ky., has developed the only college-accredited program for volumetric medical imaging. She manages the clinical team at Ziosoft Inc., whose mission is to help customers develop successful tech-based 3-D programs.

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