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 None—5 2. Do you currently have a 3D workstation? Yes—1 No—3 3. Do you currently have thin-client architecture for 3D postprocessing? Yes—1 No—3 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 you had the capacity to scan more patients—3 Very busy: the schedule is almost always full and could be much more full. You are frequently squeezing in additional patients and potentially losing business because of limited capacity—5 6. Which best describes your CT-technologist staffing level? Fully staffed, with plenty of technologists available to do 3D work 24/7—1 Adequately staffed, with the technologist capacity to do 3D work during the day, but not at night or on weekends—3 Relatively short-staffed, with technologists needed to scan patients rather than to do 3D work—5 7. Which best describes your CT technologists’ 3D interest and talent level? You have well-trained, motivated technologists who embrace 3D postprocessing—1 You have capable technologists who prefer CT scanning to doing 3D reconstructions—3 None are adequately trained in volumetric imaging—5 8. How much 3D/advanced image processing are you doing currently? More than three studies per day, with emergency and 24/7 needs—1 More than three nonemergency studies per day—3 Fewer than three nonemergency studies per day—5 Little to none—7 9. Do you have a teaching mission at your institution (resident training or research, for example)? Yes—1 No—3 10. What is the interest level among your radiologists in doing postprocessing? They want to do it all themselves—1 They want technologists to do most postprocessing and occasionally use the workstation themselves—3 They virtually never want to do postprocessing themselves—5 11. If you are currently doing any postprocessing, what is the level of satisfaction with the service among your radiologists and referring physicians? High—1 Low—5 12. Is your 3D program now, or will it be, heavily focused on a limited breadth of cases (for example, only doing cardiac CT angiography), or do you need to offer a broad array of 3D services, such as orthopedic, neurosurgical, and urological reconstructions? Narrow—1 Broad—5 13. Do you fully understand the 3D reimbursement scenario, and have you developed pro formas for an in-house 3D lab? Yes—1 No—3 14. Do you have a capital budget to support the startup costs of an in-house 3D lab? Yes—1 No—5 Scores The following scoring matrix will help you assess whether you should build an in-house 3D lab or consider outsourcing some or all of your 3D postprocessing. 14–24: You have the potential and capacity for a sophisticated, high-quality 3D lab, should you choose to build, staff, and run it yourself. 25–43: You will probably realize maximum cost/benefit returns from a blended lab, keeping some 3D services in-house while outsourcing others. 44–64: You have limited resources for providing advanced image processing in-house and would probably get the largest return on investment by outsourcing your advanced image processing to an independent lab.