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A Closer Look at the Digirad Ergo (Infographic)

Posted on: 08.23.18

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Seven mistakes to avoid when choosing between a new and refurbished nuclear camera

Posted on: 04.26.18

With the continual advancements in healthcare technology and service, investing in your cardiac practice, upgrading equipment, and improving efficiency is an ongoing process. One of the most significant considerations is not only when to replace a camera, but also if refurbished, or new equipment might be a better decision.

It’s important to take the time to look beyond your immediate imaging needs and consider the long-term goals of your practice. Both refurbished and new camera systems come with advantages, but be sure to consider these factors before signing on the dotted line:

1. Focusing only on purchase price vs. the long-term cost of ownership

A nuclear gamma camera is a significant investment for any practice, so it’s natural to focus on the cost. There are times when prioritizing price is a smart idea, but only when the product still retains an acceptable level of value. There are many refurbished cameras that have a considerable amount of life left and could be a wise investment.

When you evaluate new versus used equipment, consider how much image quality has improved in recent years, the availability of new software programs, and the viability of the camera’s current operating system. When the camera is in need of repair, will parts be readily available and will the manufacturer agree to service it? Some manufacturers include a firm end-of-service date on their equipment, which leaves you at the mercy of third-party service providers and replacement parts. Some service companies may even decline service because of age, limited part availability, and the associated risk.

2. Overlooking the ability to maintain image quality

Older, refurbished cameras may undoubtedly be in working order, but their boards and analog methodologies could be less effective. With age, the camera’s light pipe, which includes crystals that eventually yellow and crack, will no longer respond, sometimes without warning. Replacement crystals for older cameras may not be available. Even with newer refurbished cameras, the crystals have already aged, may be hydrated, and are potentially unfixable. Be sure to inquire about and examine the crystals if you’ve considering a refurbished camera.

3. Putting your HIPAA compliance at risk

Another important factor to consider is HIPAA compliance. Many refurbished cameras cannot be upgraded to current software versions, and, because they’re no longer supported by the manufacturer, they can’t they be patched securely. Consequently, the camera cannot be connected to a network because internet access imposes new risks. You also may not be able to add additional processing programs and, in the end, may be forced to purchase an entirely new software package, which will be costly.

4. Not factoring in the credit rating of the practice

While many physicians may have excellent credit, they may not be willing to put their personal credit history on the line when purchasing capital equipment such as a nuclear gamma camera. Instead, they opt to leverage the business credit, and this can have a direct impact on the approval process and interest rate.

If the practice does not have an extensive credit history, it’s more challenging to secure a loan, and interest rates are likely higher on pre-owned equipment. Additionally, if a financial institution feels that you may have issues with part availability on refurbished systems, they may be hesitant to approve a loan for older medical equipment. Be sure to discuss the details and get loan pre-approval before the sales process begins.

5. Failing to consider the true patient volume

Volume is another important factor to evaluate when deciding between used or new equipment-or even whether to outsource your imaging services completely. Not all cardiac practices need a camera on site five days a week. If you’re imaging one, two, or even three days a week, you might consider partnering with a mobile imaging company.

Your volume should factor into your financial investment. Without it, the lack of revenue wouldn’t warrant spending dollars on maintenance costs and might eventually lead to a decline in the integrity of the equipment.

6. Purchasing camera that offers limited use

Any new or used camera that you plan to purchase should be able to expand and grow with your practice. A camera should be able to fill your current imaging needs, but also serve your practice in other ways. Would it lend itself to increased productivity, improved efficiency, and greater patient satisfaction? Sometimes it may be worth the extra investment if it allows you to move forward on another strategy that has the potential to increase revenue or to reach other goals.

7. Not performing your own due diligence

Lastly, knowing from whom you’re purchasing your equipment is of critical importance. An investment of this size should only be made through a reputable company with a proven track record, especially if it’s a refurbished camera. Prepare a due diligence checklist and take the time to get better acquainted with the camera, just as you would with a home, used car, or any other purchase in the second-hand market. Ask to see it, or have it inspected by an independent service company, and ask for the repair and maintenance records.

It’s well within your rights to investigate the camera’s history, current value, and the likelihood of any future issues before making a final commitment. If you don’t, you’re exponentially increasing your chance of winding up with a lemon and having no recourse.

Cost shouldn’t be the only consideration when buying a camera. It may be high on your list, but the value it brings to your practice should be well worth the money you spend.



Intraoperative benefits of Ergo touted in the Journal of Pediatric Surgery

Posted on: 03.15.18

The portability of the Digirad Ergo Imaging System is making a significant impact in the pediatric oncology world. The Journal of Pediatric Surgery recently published an article on its intraoperative use. Most notably, it reported on how nuclear imaging with the Ergo effectively reduces the time under anesthesia and offers real-time confirmation of lesion removal. Digirad recently spoke with Dr. Marcus M. Malek of Children’s Hospital of Pittsburgh of UPMC, to further elaborate on the study.

Single environment reduces time under anesthesia

In order to guide lymph node biopsy, pre-surgery lymphatic mapping is done via lymphoscintigraphy. Adults and teens are generally able to tolerate the procedure while awake. It does, however, involve an injection and the need to remain still, which can often be difficult for a child. For that reason, young pediatric patients, and some adults for that matter, are sedated and mapped in the nuclear medicine suite and then transported to the operating room. The additional step takes a considerable amount of time and coordination, which leads to downtime in the OR.

The portability of the Digirad Ergo allows the patient to be anesthetized while they’re in the operating room. Prior to the start of the surgery, the nuclear medicine technologist or physician injects the radiotracer in standard fashion. After the tracer has moved to the area of interest, the Ergo acquires the images needed for the lymphoscintgraphy. Once the sentinel nodes are marked and the area is prepped, the surgery can begin without delay. When the procedure and the surgery are done in one environment, it’s safer for the patient, spares them additional time under anesthesia, and alleviates the need for transport.

Visual confirmation in real-time

Beyond reduced anesthesia time, a camera in the operating room allows the surgeon to confirm the lesion of interest has been removed in real time. Certainly, a preoperative lymphoscintigraphy can help with mapping, but it cannot visually confirm the lesion’s removal. The Ergo allows confirmation of lesion removal or, in some cases, identification of lesions that were thought to be removed or hidden behind another. Visual representation is a fail-safe that ultimately improves surgical outcome.

In the past, some have equated portability with lower quality images, but the Digirad Ergo doesn’t trade one benefit for another. It delivers high-quality images that technologists say rival any static nuclear camera and its compact, portable design offers maximum clinical versatility.

Read the full article, Use of intraoperative nuclear imaging leads to decreased anesthesia time and real-time confirmation of lesion removal , at the Journal of Pediatric Surgery.



A Closer Look at the Digirad X-ACT+ (Infographic)

Posted on: 03.01.18

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Is a single-head camera acceptable in today’s market?

Posted on: 01.25.18

As nuclear cardiac imaging technology has evolved, gamma cameras have graduated from single-head to multiple-head detector technology. Although single-head SPECT cameras are not necessarily obsolete, there are an increasing number of drawbacks if you choose to continue using it to diagnose cardiac patients.

Dual-head cameras reduce scan time by half, simply because there are two heads. Each rotation is only 90 degrees compared to a single-head that is responsible for the full 180 degrees. A triple-head camera can complete a scan in about one-third of the time of a single-head camera.

The popularity of Gated SPECT

In years past, higher vs. lower volume dictated the need for a single or dual-head camera. But, as technology evolved, gated SPECT (GSPECT) became state-of-the-art and grew into one of the most frequently performed procedures in nuclear cardiology. The additional combined minutes of scan time needed to gain enough count density was significantly improved with a multi-head camera.

Nuclear medicine is, by all counts, a low statistic science. Anything done to lower the statistic results in an inferior image, and consequently, anything done to increase the statistic improves the image. The goal is to use as little dosing or time as possible to reach the medical diagnosis. By using a multi-head camera, you may increase the total counts per stop, thereby improving the counting statistics with a significantly shorter total scan time and/or lower dose, resulting in a better image.

From the patient’s perspective

Time is not only relative to the procedure and your overall volume, but it’s also important to patients. A higher quality outcome completed in less time leaves the patient with a better overall experience. It also allows them to be more compliant during the scan. A patient who can remain still results in a better image than one from a patient who moves, even if the image is motion corrected. In fact, the correction itself can create artifacts. Consider the practicality, too. When a patient is uncomfortable or in pain, a procedure that finished even five minutes sooner could make a world of difference.

Improving your single-head camera

Over the last decade, advanced reconstruction algorithms, like Digirad’s nSPEED™, have been developed to mathematically improve statistics. Today, if your single-head camera doesn’t include the algorithm, you can invest in a software package, which can increase the speed of the scan time without degrading the image.

While software upgrades can lead to improvements of a single-head camera, a multi-head camera is still faster, includes higher statistics, and results in a better image. You also won’t benefit from all the other advantages should you have chosen to replace your equipment. It simply might not be the best available use of your time, energy, or money.

Upgrading in today’s market

If you upgrade your equipment to a dual or triple-head camera, your advantages are significant.

Today, advanced reconstruction algorithms are standard features, so you’re choosing to improve the image quality in half the time, thereby increasing your lab’s overall efficiency. You’ll also have access to the latest versions of software.

A dual or triple head camera also gives the technologist the flexibility to deliver the very best image. A multi-head camera with an advanced reconstructive algorithm can offer improved image quality and lead to a more confident and accurate diagnosis. Additionally, with tools like Digirad’s TruACQ Count-based Imaging™, each scan is fully personalized to each patient by quickly reading the activity originating from the myocardium prior to the scan, and recommending the appropriate seconds per stop to meet ASNC count density guidelines. This individualized care doesn’t prolong the technologist’s workday because they have the tools to do the best job possible.

Upgrading is not just about how many detector heads your system has. It’s investing in a better and more sophisticated way to deliver nuclear cardiology.



What to do when your volumes are low and you still own a camera

Posted on: 11.02.17

During the late 1990s and 2000s, many practices chose to purchase a cardiac camera. Reimbursement rates were consistent, testing volumes were high, and from both a patient care and an economic perspective, it made sense to invest in the equipment.

Shortly thereafter, a series of changes in the industry made ownership more challenging. Major insurance companies instituted a cut in nuclear cardiology reimbursements, payers implemented strict imaging pre-authorization requirements, and additional accreditations became required to operate a nuclear lab.

These shifts in the market have made ownership more challenging for physicians that still own their nuclear camera. While many practices may no longer have a loan left on their camera, they still have costs associated with its use, including the licensing, physics consultation, monthly maintenance, isotopes, consumables, and the technologists. The question many doctors have is “What do I do now?”

How are physicians addressing the problem?

Physicians have turned to a number of approaches to address the problem of increased costs and reduced reimbursements. These approaches include:

Staff Changes: Reducing the number of technologists is the obvious and first choice for physicians looking to reduce costs. If you’re seeing a drop in imaging volume, it only makes sense to have the staffing choices be based on that number.

Reduce Imaging Days: If you have a camera sitting in the office it may seem like offering imaging every day makes sense, but that decision can easily drive up costs. Bundling patients and scheduling them for specific days is a way to increase efficiency. Making this move can allow you to make your technologists part-time and keep the existing team vs. letting parts of the team go. Only paying for one or two days a week is much more cost effective if volumes are down.

Negotiating Lower Rates: Some practices have had success with negotiating lower rates on isotopes, consumables, and supplies. Additionally, the cost of the physicist and audits is negotiable so that can be an area to explore. The limiting factor with this method is leverage. Smaller practices that purchase a limited amount of supplies will not get the discount that larger practices may receive.

Partial Outsourcing: Many physicians are turning to outsourcing and bringing in outside vendors to provide elements of the service, particularly around staffing. By not having the full-time employee obligations they can easily scale their expenses to match volume. The quality and the consistency of the technologists are critical here because the team is a reflection of the practice when they’re imaging patients.

The Benefits of Comprehensive Outsourcing

Comprehensive outsourcing is a bigger decision, but it’s one that could result in the greatest cost savings. Under a comprehensive outsourcing arrangement, the outsourcing provider delivers the staff, consumables, accreditation, radiation materials license, etc. Patients are imaged at your office, but the financial burden of operating the nuclear lab is on the outsourcing partner, not your practice. Financially this works because the provider is paid a percentage of the reimbursement, so the upside is much clearer. Image and you earn a profit, don’t image and there is no penalty.

Programs such as Digirad Select provide a nuclear medicine technologist or cardiac stress technician that handles the imaging in your office, with your existing camera. Other package options include equipment, licensing, supplies, pre-authorizations, repair and maintenance, and accreditation.

Comprehensive outsourcing providers, like Digirad, are able to make the numbers work largely due to leverage. By working with thousands of practices across the country, the rates they are charged are lower, and this creates efficiencies that lower costs and increase the quality of the service.

Regardless of the options you choose to implement, it’s important to stay ahead of trends in both technology and the reimbursement landscape. Managing your overhead will protect your ability to help future patients as the market evolves.



How is PET/CT different from traditional PET imaging?

Posted on: 10.12.17

Today, most of the Positron Emission Tomography (PET) scanners you find in hospitals, or delivered via mobile imaging, are actually PET/CT cameras. Modern PET/CT scanners combine both PET and Computed Tomography (CT) scans almost simultaneously to provide a greater amount of clinical data to assist in the diagnosis process.

Combining the benefits of PET and CT

A PET/CT scan includes two parts: a PET scan and a CT scan. The CT portion of the scan produces a 3-D image that shows a patient’s anatomy. The PET scan demonstrates function and what’s occurring on a cellular level. The PET scan is unique because it images the radiation emitted from the patient while the CT records anatomical x-rays, showing the same area from another perspective.

The role of attenuation correction

PET/CT scans not only pinpoint localization; they also offer significant help with attenuation correction, a huge advantage. During a CT scan, the system records numbers, called Hounsfield units, which measure the density of the tissue that it travels through. Not only does the CT produce images, but they also have numbers assigned to each individual pixel.

The PET scan measures the level of radiation coming from the patient and compiles information that the system needs to decipher. It uses algorithms and corrections, including the Hounsfield units from the CT scan, and adjusts the images in accordance with the corrected densities for each region.

In the 1990’s or early 2000’s, a PET-only scan would have used a transmission scan for attenuation correction or forgone it completely. Today, however, there is better technology available. Using both CT and PET to cross-check data and corroborate each other is a way to increase confidence and reduce guesswork. It gives significantly more data points to reference in order to determine a diagnosis and treatment plan.

PET/CT is more than just oncology

One of the biggest misconceptions about PET/CT is that its benefits are limited to diagnosing cancer. There are many new uses that are benefiting from PET/CT technology that fall outside of oncology. For example, in neurology, a brain CT or MRI only looks at the structure. The benefit of looking at function through an FDG-PET scan is that a functional change on the cellular level will be seen before a possible structural change. The same can be said for cardiac imaging, epilepsy, Alzheimer’s disease, dementia, infection and inflammation and a host of others. These are areas that could benefit from taking advantage of the advancements in the PET/CT world.



How to reduce your dose with SPECT MPI studies

Posted on: 10.05.17

Advancements in medical imaging technology have revolutionized health care, allowing doctors to more accurately diagnose disease using SPECT for MPI scans. Any time a physician orders an imaging scan, however, there is always concern about the level of radiation exposure.

ASNC and SNMMI are raising the bar with their guidelines, and the industry as a whole is moving toward a low dose standard. What does that mean and how will that change impact your practice? Here are some resources that will help you better understand and adopt a low dose protocol.

Implementing a low-dose protocol (link)

If you are considering the implementation of a low-dose protocol, you’ll need to evaluate three important elements within your practice: proper patient segmentation, commitment, and technology.

Patient Segmentation

Proper patient segmentation is a large part of implementing a low-dose protocol because each patient is a unique combination of age, weight, shape and medical history. Did you know that ASNC estimates half of the patient population falls under the appropriate criteria for low-dose? Following the ASNC guidelines can help physicians decide when to reduce radiation exposure in order to optimize patient care.

Commitment

It only takes one physician to publicly advocate low-dose imaging to get the conversation started. With this progressive thinking, however, your practice will have to collectively adopt a new low-dose culture. The physicians, both referring and reading, must be committed to a low-dose protocol in order to successfully implement the change. It will require further education, training, leadership, discipline and diligence along with a “can-do” attitude from all parties.

Technology

With a low-dose protocol, the goal is to acquire an image with sufficient quality for maintaining diagnostic accuracy. Maintaining image quality while reducing the patient dose is a challenge, but new technology makes it possible. A multi-head camera, combined with nSPEED reconstruction software and Tru-ACQ Count Based Imaging provides fast acquisition times with the lowest appropriate dose.

TruACQ Count Based Imaging™ is the first and only count-based SPECT imaging technique that ensures consistent counts for every patient study, regardless of the patient’s size, weight, or the dose used. The proprietary software is designed to simplify the decision-making process around acquisition time. TruACQ™ takes a quick look at exactly what the detectors are picking up, which accounts for all possible variables, and provides the optimal scan time for the patient being imaged. The result is the highest quality image in the shortest amount of time.

Stress-Only Protocol (link)

Another way to help lower the radiation burden to patients is to adopt a stress-only protocol. Stress-only protocol is the directive by which a medical provider performs a cardiac stress test without the complementary resting scan. Traditionally, both a resting scan and a stress scan are performed on patients, which are then compared to more confidently support a diagnosis. Often, what could potentially be an abnormality in one image is disproved by the other, thereby reducing inaccurate conclusions. It does, however, subject the patient to two radiation doses, sometimes unnecessarily.

Those with a low probability of heart disease, typically younger patients who have limited risk factors, are the ideal candidates to forgo the resting scan and follow the stress-only protocol. Not only does the protocol support the global drive to decrease the radiation burden to patients, it also reduces costs, and saves time.

Easing concerns (link)

The word radiation may stir-up heightened concerns, especially if a patient is having multiple tests performed. How much radiation is considered safe and over what time period? Do some tests bring greater exposure than others? At what point should they become concerned? These are all valid questions. The bottom line is that medical imaging is a safe, painless, and cost-effective way to diagnose and treat disease.

Is there a real risk?

Any medical procedure can have side effects, but when the procedure offers useful clinical information that will help your physician decide on your treatment, the benefits of the procedure far outweigh its very small potential risk.

The decision to implement a low-dose protocol is an important step for both you and your patients. Keep in mind that not every patient is required to be low-dose for your practice to be considered a low-dose lab. In the end, it’s about lowering the radiation burden to your patients more than you are now.



Best practices for coding nuclear medicine scans

Posted on: 07.27.17

In recent years, billing for nuclear scans as it relates to coding, has been modified to more accurately reflect the provider services and thus, reimbursement for patient care. We are finding, however, that in internal medicine offices or cardiology groups, where there would likely be fewer conversations about these changes than in a nuclear practice, more clarification may be needed.

Decoding the billing code process

To be clear, the coding itself has not changed, but who can use designated codes have changed. Medicare is very specific as to the way in which they require the submission. The most confusion comes with the series 93015 through 93018 codes. With any test, there’s a differentiation among whether you supply the equipment, supervise the procedure, or interpret the report. Billing for anything other than your specific function, especially when it pays a higher fee, leads to non-compliance and possibly additional scrutiny via an audit. These are typically innocent mistakes that can lead to much larger issues. With that in mind, here is a list of basic codes for billing MPI SPECT that may be helpful:

  • 78452 – Multiple Myocardial Perfusion Imaging, at stress and at rest. This code should only be billed once.
  • A9500 – The “A” series codes relate to radiopharmaceuticals. A9500 represents Technetium tc-99m sestamibi, diagnostic. This is a per study dose and should be billed for 2 units. If sestamibi is used, bill NDC code 65857-0500-05.
  • J0153 – The “J” series codes describe drugs. J0153 represents an injection of adenosine – this should be billed 1 unit for each milligram. You might also use J2785, an injection of Lexiscan and should be billed for 4 units.
  • 93015 – This is the global code for cardiovascular stress testing. 93015 should only be used if your practice owns the stress equipment and your physician can interpret the test and issue the report.
  • 93016 – The second in the cardiovascular stress test series, this code should be used if you provide supervision only, without interpretation or report.
  • 93017 – The third in the cardiovascular stress test series, this code should be used if you provide tracing only, without interpretation or report.
  • 93018 – The fourth in the cardiovascular stress test series, this code should be used if you provide interpretation and report only, without supervision.

Using the correct codes is critically important for accurate reimbursement. Knowing which codes to use and why helps increase overall compliance and, above all, properly reflects the procedure that was performed.



What is Fluorescence Attenuation Correction?

Posted on: 07.20.17

Attenuation correction is a process that identifies and corrects for soft tissue artifacts in SPECT images. Ultimately, the goal is to minimize the visual impact of attenuation in order to provide images that more accurately portray the distribution of imaging agent in the patient. This results in higher reading confidence, improves diagnostic accuracy, and lowers the incidence of false positive studies thereby reducing the number of unnecessary diagnostic cardiac catheterizations.

Traditional attenuation correction methods

Historically, there were two primary methods of attenuation correction, line source, and CT. While line source attenuation correction is a valid method and is still currently used, its biggest disadvantages include the challenging number of mechanical failures, the difficulty of use, line source decay yields imaging quality issues as a function of time and has expensive replacement cost. For these reasons, users often opt for an alternative method when it’s time to consider replacing or upgrading equipment.

CT attenuation correction is a popular method primarily used in the radiology and oncology fields where the CT can be used for diagnostic purposes. However, for a dedicated cardiac environment, the high cost of a SPECT-CT system is unsustainable. Additionally, the costs of constructing a shielded room can be greater than the scanner itself.

The lack of viable options for Cardiologists has resulted in patients being without the benefit of attenuation correction. However, Cardiologists who want to offer attenuation correction are leveraging a new, third method – Fluorescence Attenuation Correction.

Fluorescence Attenuation Correction – Low dose and low cost

Fluorescence attenuation correction utilizes a fluorescence X-ray thus allowing for a lower dose and less radiation exposure to the patient. The method is a unique combination of hardware and software technology that allows for the delivery of superior image quality at the lowest possible radiation burden (less than 5 microsieverts).

From a cost standpoint, FAC does not require room shielding and uses the same detectors as the SPECT system. The homogenous pattern of the fluorescence X-ray also contributes significantly to a better, cleaner image and substantially increases diagnostic confidence.

Currently, fluorescence attenuation correction is only available in conjunction with the Digirad X-ACT+ camera. Although attenuation correction is not new to the industry, Digirad’s methodology is able to offer a significant improvement from a reliability, exposure and cost standpoint. The X-ACT+ uses an optimized design to bring benefits of attenuation correction to the cardiac patient, physician, technologist, and facility. The end result is more accurate results, less false positives, and less needless additional testing which means less radiation burden for patients and lower costs to the payer systems.



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