In-house vs Outsource for 3D: A Questionnaire for Determining the Breakeven Point

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It’s coming. In many hospitals, it has already arrived. We’re talking about multidetector CT (MDCT), CT angiography, and advanced 3D imaging. This wonderful new technology offers the promise of evaluating disease processes, from atherosclerosis to cancer to trauma, more quickly, safely, and accurately than older techniques. CT angiography is already replacing diagnostic catheter angiography in many institutions. Everything from chest pain in the emergency room to brain perfusion in acute stroke to complex presurgical planning is now requiring some degree of advanced image processing. New applications for this technology are being developed every day. It is clear that advanced image processing has moved from luxury to necessity in the practice of medicine.

A hospital’s adoption of sophisticated 3D imaging, however, entails several important steps, with many factors to consider in order to be successful. Foremost among these factors is, of course, the cost of developing a 3D lab. Now, with the ability to outsource your 3D postprocessing, it is important to consider whether outsourcing all or part of your 3D work makes financial sense. Unfortunately, from a strictly financial standpoint, it virtually never makes sense to use your valuable CT technologists for postprocessing cases. The reimbursement for 3D work is simply so low, compared with the technical reimbursement for the CT scan, that the opportunity cost of doing 3D postprocessing is huge. Opportunity cost is defined as the difference between what you made doing what you did and what you could have made doing something else more profitable—in other words, the lost opportunity.

A recently published study by Boland et al1 at Massachusetts General Hospital drives home this point. By assigning three technologists to each scanner instead of one, annual productivity on the scanner improved by as many as 30,000 examinations per year, yielding as much as $4 million per year in additional revenue. If your hospital is fully staffed and operating in a saturated market, you are probably best served by keeping at least some of your 3D work in-house. Certainly, time spent doing 3D postprocessing is better than idle time. On the other hand, if your scanner is busy and could be busier in your market, it is probably not in your financial best interest to pull technologists away from routine CT scanning to do postprocessing.

Therefore, the decision to develop in-house 3D capabilities (versus outsourcing) must be made on the basis of more than a simple financial model. Subjective factors should certainly play a role. Some of the factors influencing your decision on 3D include an analysis of the role that your technologists and doctors wish to play in 3D postprocessing, the talent level and interest of your technologists, and the role that your department may play within a training and teaching institution. I have developed the following questionnaire to assist you in organizing your thoughts about 3D postprocessing and how it should best be handled by your institution.

For each question in the following survey, please choose the one answer that most accurately describes your organization. You will note that some answers are weighted more heavily than others in points, based on importance. The questions form a realistic framework for examining important factors to consider in developing a 3D service, including upfront capital costs, hardware/software capabilities, PACS and networking, the opportunity costs of doing 3D work, technologist training and interest, physician interest and satisfaction, teaching mission, and case mix. Total your points and see which model makes the most sense for developing an advanced 3D service for your hospital.

Begin Questionnaire

1. Describe your PACS:

Fully integrated among multiple sites—1

Single-site or nonintegrated multiple sites—3


2. Do you currently have a 3D workstation?



3. Do you currently have thin-client architecture for 3D postprocessing?



4. Describe your organization:

Multiple hospitals connected by a high-bandwidth LAN/WAN—1

Multiple hospitals with limited (or no) broadband connectivity—3

Single hospital—5

5. Which best describes your hospital’s potential CT market share?

Low-volume market with relative oversupply of CT scanners: It would be difficult to increase CT scan volumes—1

Moderately busy: generally a full schedule, but could add several patients per day to the schedule if