This month TechNation reaches out to CT experts to find out the latest about this medical imaging technology, including some of the challenges the industry is facing in 2015. Our panel includes Scott Anderson, Director, Technical Operations, Ed Sloan and Associates; Paul M Fernandez III, Regional Service Manager, Consensys Imaging Service; Leon Gugel, President, Metropolis International LLC; Sarah Lee, Vice President of Sales, Medical Imaging Technologies Inc. (M.I.T.); Jeremy R. Probst, Chief Operating Officer, Technical Prospects; Nathan Struiksma, Field Service Manager, Southwest Medical Resources; and Randal Walker, Vice President CT and MR, BC Technical.
Q: What are some of the latest advancements in CT equipment and how will they impact the market?
Anderson: Dose reduction awareness is one advancement that has been in the spotlight lately. Throughout my career this has been a hot-button issue for me. In my travels, I was always amazed at the wide range of techniques used for the same protocol, even on the same model of scanner. When the high power systems became the norm, the techniques rose to match the systems capabilities but didn’t necessary improve image quality which led to over exposing patients. The pros for dose reduction is obvious, the cons are that some older mulitslice scanners won’t be retrofitted and will get pulled from service even though they are still fully functional and viable scanners if they were used correctly.
Fernandez: Low dose options in the hardware and post image processing are reducing patient exposure to ionizing radiation. XR29 has generated focus on radiation dose reduction while maintaining image quality. Some methods include increasing the slice count and reducing scan times. Other improvements include advanced reconstruction, improved time-saving workflow enhancements and advanced detector technology. The result is improved patient care.
Struiksma: One of the latest advancement in CT equipment has been dose-tracking software to accurately calculate patient dosing during a CT exam. The OEMs have also started to release their own dose-tracking software on their latest versions of equipment.
Walker: Low dose will impact CT over the next few years. NEMA, The Joint Commission and ACR are all weighing in on the responsibilities of the technologist, doctor and hospital in minimizing the radiation the patient is exposed to while still providing good early detection/diagnosis.
Q: What are some of the biggest challenges of purchasing and maintaining CT equipment today?
Anderson: When buying any expensive piece of medical equipment you should do your homework. Before you sign on the dotted line, have an expert inspect the system. You wouldn’t buy a used $200,000 car without getting it checked by an expert. Use a reputable vendor that stands by what they sell, if possible get a warranty. It is always a good idea to check for parts (tubes included) and service cost and availability. What may seem like a good price for a scanner today may cost you in the long run if operation costs are high. Cavet emptor.
Fernandez: The obvious challenge is budgeted funds which dictates whether to purchase new from the OEM or a used/refurbished scanner. If purchasing new, remember to account for the cost to repair after the warranty period ends. Many new systems will not have the option to be serviced by most third-party organizations so the OEM may be the only option for service and parts (premium cost.) If purchasing a refurbished unit, be sure to do your homework on:
- Who is selling the equipment?
- Do they have qualified FSEs that can install and offer continuing service?
- Is the X-ray tube available in the aftermarket or only through the OEM?
- Do they have access to quality (FDA-compliant) parts at reasonable costs?
- Can you obtain a service history on the pre-owned equipment?
Maintaining the equipment comes down to negotiating a reputable, affordable and FDA-compliant service agreement. Obtaining an equipment uptime of 95 percent or better, with adequate on-site response times as well as high Mean Time Between Failures (MTBF) to help ensure high patient throughput, are all critical factors to consider.
Gugel: The high cost of tubes and certain other specific parts, especially when systems are not properly maintained in the first place, are some of the biggest challenges when it comes to CTequipment.
Lee: Government regulations like XR-29. If you don’t want reimbursements to be cut you have to comply and some people are having to buy new CTs altogether or having to pay a lot to get the software to make it compliant. They could come out with new regulations at any time that cost more money.
Probst: Today’s high-tech CT scanners require expensive X-ray tubes and service contracts. The cost of service (OEM, in-house, alternative) and availability of X-ray tubes, parts and technical training are among the challenges health care facilities face. In an effort to lower cost, you are seeing a shift away from OEM service contracts. If a facility understands the risk factor, they will make an educated decision to assume more risk and – in most cases – save money over time.
Struiksma: One of the biggest challenges in servicing CT equipment would be parts availability, cost and reliability.
Walker: The balance between the price of the equipment and the technology that is being acquired versus the reimbursement for the clinical studies that can be accomplished is the issue in purchasing CT. The challenge in maintaining the CT is two-fold: 1. Getting the best cost to value you can get from a service provider. 2. Maintaining the equipment as long as possible before changes in regulation or technology hamper your ability to get reimbursed or to maintain your patient base. In the cost to value proposition, each facility has to measure its ability to deal with risk (i.e. tube replacement or equipment failure) to the cost to mitigate that risk by signing a service agreement.
Q: What are the most important things to look for in a reputable third-party CT equipment provider?
Anderson: The easy answer is reputation, the third-party industry is relatively small and with a few phone calls one can usually find a provider that will suit their needs. One of the biggest things people look at today is the field service engineerer’s training, while this is important it shouldn’t be the only question. Training is great mind you but if you haven’t worked on the system you were trained on in four years, experience trumps training. I also ask for insurance verification from vendors.
Fernandez: At minimum, they should have a documented quality management system in place. If possible seek-out organizations that have taken the additional steps to become and maintain certification to ISO 9001:2008 and/or ISO 13485:2003. This will ensure the organization has well-defined processes and procedures for consistently servicing and obtaining parts that meet various regulatory requirements governing medical devices. Are the Field Service Engineers certified to install, PM and maintain your equipment? If FSEs are certified, how do they maintain this certification? Does the company have a service escalation process? What is the company’s on-time PM completion percentage? Check references and be sure to inquire about reliability.
Gugel: Service and the ability to work with software systems, not just the mechanical components is important.
Lee: Make sure you call multiple references. Some people are one-man shows and that is fine if they know what they are doing and only have a couple of customers, but you don’t want your CT to break and them be on another site and not have someone to send to fix yours. Also, some people say they refurbish CT and all they do is paint the covers. Then, if it starts breaking a lot they give the rest of the third-party companies a bad name. So just make sure they have a good reputation
Probst: I would look for a provider with processes that are tried and true. If they refurbish equipment take a tour and evaluate the people, facility and processes as you are making a large investment. If you are buying used equipment with a turn-key installation review the company’s project management program and ensure they have seasoned engineers, room planning drawings and a contract that protects both parties. Reputable companies stand behind the equipment that they sell with either a warranty or service contracts.
Struiksma: One of the most important things to look for when choosing a third-party provider is, can they deliver what they offer? There are a lot of options to choose from and some of those options look great on paper but you need to do some investigation and see what resources they have in place in order to accomplish the job.
Walker: Three things highlight a quality, independent CT equipment provider. One, the facility and the and staff to do a quality remanufacture of the CT. Two, the ability for the customer to see and scan on the system during refurbishment and prior to delivery of the scanner that they purchased. Three, a field service team that can properly support the warranty and the unit for service after warranty.
Q: What else do you think TechNation readers need to know about purchasing and servicing CT?
Anderson: Reputation is the biggest key for me. It doesn’t matter how big or small the provider is, to me it’s can I count on them to be fair and reliable? Cost shouldn’t be the sole determining factor for service or procurement, sometimes you do get what you pay for. An example would be if I could get a tube changed for $3,500 and it gets done right in seven hours versus two days for $2,000, I am paying the extra $1,500.
Fernandez: Truly get an overall understanding of the department’s needs prior to making a purchase. Knowing what is important to them will help steer the purchase including their post install service requirements. If buying a used unit is a viable option, do your homework and you can save a lot of money using a reputable third-party provider. Also focus on maximizing your productivity by identifying proven legacy CT systems which have reliably provided high image quality and don’t just assume “more slices” is better for your needs.
Gugel: Price, capability and expected life usage are all things to consider.
Lee: Use a third-party if the company has a good reputation. It will save you a lot of money purchasing equipment and service from them. Also, third-party companies are not huge like the OEM so they still care about the customer. Usually when you call they will be on the way immediately to check it out instead of pushing you to the back burner for a little while.
Probst: If you are buying pre-owned or refurbished equipment you have the luxury of looking for models that have excellent after sales support by the third-party market. Many times the most cost-effective equipment up front is not the most cost-effective to support. There are many differences in a “refurbishment” or “reconditioned” piece of imaging equipment. Make sure to do your homework and ask the key questions that will set one vendor apart from another.
Struiksma: Realistic needs versus the latest and greatest. In purchasing and servicing you need to evaluate your needs and get what fits your needs best. Much like shopping for a used car you can get a brand new, big impressive car that may feel great but in the long run it may be better to get the less impressive car with better reliability. They both of drive down the road, but do it in a different way.
Walker: Seeing and scanning on the unit you are purchasing assures you and your staff are getting the system that meets your needs. Purchasing from someone who won’t or can’t let you see your system can be problematic at the time of installation completion and system turnover. It is better to have the chance to get all of your concerns addressed prior to paying the final payment.
Q: What else would you like to add or do you think is important for biomeds to know about CT equipment?
Anderson: If you’re serious about servicing CT scanners, I would suggest the following steps. 1. Thoroughly read the safety section of that system’s service manual. 2. Find an experienced mentor and tag along on some PMs, even if it’s on your own time, it will pay dividends later. 3. Read, read and then read some more, start with the theory. 4. Once you have some exposure and feel comfortable, book a class with a company with trainers who have real experience on that system, you don’t want a lesson plan reader.
Fernandez: One critical factor in properly maintaining CT systems is to complete comprehensive PMs per manufacturer’s recommended schedule and checklist. A CT combines ionizing radiation, sensitive imaging detection circuitry, high torque motion assemblies and, in some cases, liquid cooling plumbing. It’s very important to remember personal safety, including radiation hazards and compliance with all state and federal regulations (state registration, timely submission of 2579 Forms, etc). Depending on whether the unit is air or water cooled, there will be different preventative maintenance requirements. Know your torque specs. Over/under-tightening can lead to metal strain, loose assemblies and equipment failure. Also, another very important tool you have is your ears – listen to the pitch, oscillation, and rhythm during high speed rotations. An experienced ear can identify problems not found in other test results.
Gugel: Systems must be able to be easily serviced and maintained with parts – not just purchased from a cost-only basis.
Lee: It helps save the department time and money if one of the biomed personnel can learn to do first call that way when they call the service engineer they can already have an idea of what the problem is and have the parts to fix it when they come.
Probst: It is important to be aware of third-party companies providing specific technical training on many manufactures CTs. Along with training having access to X-ray tubes (alternative/new/pre-owned), quality-tested parts and technical support will help lower the overall service cost significantly. Our company focuses specifically on Siemens however there are many others offering GE, Toshiba and Philips support.
Walker: Like all electronic systems it is important to have the most reliable system you can get. Partnering with a company that will let you see your system prior to delivery and one that is flexible in providing the biomed staff training for first response on repair should be deal breaker for those that can’t meet the grade.
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