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Leaps in scanning efficiency on horizon at NIC

Case Study
Orrison, WilliamLas Vegas, Nevada Imaging CentersUSA

Leaps in scanning efficiency on horizon at NIC

Philips has developed an MRI system Utilization Services tool to analyze information routinely gathered in the scanner's service log. The new tool accesses data - such as system idle time, interval between scans, patient preparation time, sequence acquisition times and entire scan times - and provides it in a unified graphical format. The result is an immediate visual, and often dramatic, representation of the scanning efficiency of a center's MRI system and scanning practices. Nevada Imaging Centers (NIC, Las Vegas, Nev.), one of three sites testing the software in a three-month pilot project, was able to increase its system utilization from 60 percent to 75 percent soon after implementing practice changes, says NIC's William Orrison, M.D.


 William Orrison, M.D. Nevada Imaging Centers,<br> Las Vegas
William Orrison, M.D.
Nevada Imaging Centers,
Las Vegas


For years, Philips' Remote Service Network (RSN) has quietly monitored and gathered operational data from the hundreds of MR systems worldwide tethered to RSN via an ultra-secure Internet connection. Until recently, RSN's main benefit was the possibility to preemptively address system problems, but Philips has engineered an ingenious new way to repurpose RSN: probing the scanner's log files to analyze system utilization.

An opportunity for greater efficiency

In December 2006, Philips representatives approached NIC officials to solicit their participation in a 90-day utilization management pilot project involving three North American sites. NIC is a highthroughput imaging group with five locations in the Las Vegas area. NIC operates a Philips 3.0T system and a Panorama HFO. The 3.0T system enables the center to perform advanced studies, for example, those requiring high SNR and/or high spatial resolution, at a high patient volume per day.


"We knew for a long time that through RSN, Philips could monitor our Intera 3.0T for repair purposes," says William Orrison, M.D., NIC radiologist. "What we didn't know was that we could consolidate information from the system log files into a program that we could access on demand via the web (NetForum Community) and examine. When they showed us the utilization data from our system in a graphical format we were astonished. Our scanner was idle - it was doing nothing - 30 to 40 percent of the time."


A significant additional incentive to evaluate the software is the impact that the Deficit Reduction Act (DRA) - which will reduce MRI study reimbursement by as much as 20 percent - will have on many American imaging centers, says NIC business advisor, Peter Cartwright. "The only way to survive in this environment is to increase efficiency. But, like many other centers we didn't appreciate exactly where our efficiencies and inefficiencies lie," he says. "The Utilization Services tool is enormously illustrative to use in terms of isolating the factors that are limiting our utilization."

The value of a graphic

The actual percentage of system idle time aside, Dr. Orrison recalls that this statistic had much greater impact when Philips representatives displayed it side-by-side with other time-related MR scan data in a colorcoded graphic. (see graphic). Among other coding, dark blue is assigned to live scanning  intervals and gray to system idle periods.


"Radiologists are visually-oriented. You can tell me that 40 percent of the time my system is not being utilized and I will probably dismiss it," he observes. "But, you show it to me on day-by-day, week-by-week graphs, including the hours each day and the gaps in the schedule where the system is just sitting there, then all of a sudden those pictures just slam you in the face and you realize how intensely you want less of that gray. For me, it was one of those 'aha!' moments."


Cartwright agrees: "Instead of simply telling our staff that we're not running very efficiently, we were able to show them graphically and they responded very well to that."




Example output of the Utilization Services tool on NetForum. It shows minute-by-minute actual system use during one day (0:00 am to 24:00 pm). Gray areas represent inactive time and waiting time, blue areas represent patient preparation and actual scanning. When placing the cursor on a blue area, the ExamCard protocols pop-up.

Pilot project helps identify sources of inactive scanner time

Not surprisingly, Dr. Orrison and his NIC colleagues volunteered to be one of the three North American pilot sites for utilization management and began using the software tool in January 2007. Dr. Orrison's team immediately identified time-wasters at NIC that contributed to excess gray space on their daily utilization log and set out to implement solutions.


One the most significant contributors to gray space were "no-shows," in which patients not only did not show up for their scheduled scan, but also did not notify NIC about their impending absence. No-show-no-calls were a completely random problem that could not be predicted and preempted, according to Dr. Orrison.


"We implemented an aggressive 'call-the-patient-the-night-before' routine, so that if we were unable to reach the patient, we would start planning to bring in an alternate patient to fill the slot," he explains. "Frankly, we also had to move no-show-no-call patients to non-prime-time slots, such as last slot or first slot of the day so we didn't lose prime time to them. It is basically a 'one strike and you're out' rule as far as prime-time scheduling."


Another time-waster at NIC was the lag time between patients. The solution to this problem was to hire a full-time technologist aide, whose duties are to prepare the patient for scanning, have them fill out paperwork, discuss the upcoming scan and record relevant patient history. "Essentially, when the door to the system room opens, the patient is ready to walk in so the technologist can just continue preparing the scan," Dr. Orrison says.



This graph illustrates that the average number of patients scanned per day increased after hiring the technologist aide.



Although a RIS upgrade hadn't yet been implemented in March 2007, the results from the utilization management tool made the upgrade inevitable. "For two years, we considered upgrading the RIS, but once we realized our overall inefficiencies with scanner use, we were determined to attack the problem in every way possible," he says. "Using the existing system, the technologist has to individually type in all the data, there is no worklist on the scanner. The new RIS has a technologist worklist, the data are all propagated automatically so names don't have to be typed, and it will track the patient through the scanning process. The new RIS will allow us to be much more efficient with our time.


Waiting to start intravenous lines until the patient is on the table means the scan won't start until this step is complete, adding to system idle time, Dr. Orrison adds. Therefore, patients requiring contrast receive their IV lines outside of the scan room now, to increase active scanning time.

Avoiding protocol "mission creep"

Because the Utilization Services tool also tracks overall examination times and the scan times of individual sequences comprising protocols, Dr. Orrison was able to appreciate very quickly that NIC was suffering from what he calls protocol "mission creep."


"All sites tend to add sequences to protocols - but it's unlikely that they would take them away. There is a 'mission creep' factor," he remarks. "What happens is you're doing a brain sequence and you decide that a particular sequence really ought to be performed in some of your patients. Accordingly, you add that sequence, then you add another, and pretty soon, protocols are getting longer and longer. Before you know it, 'Mrs. Jones' has been in the scanner from 8:00 to 9:30."


Dr. Orrison's solution was to create many new protocols tailored to narrowly defined applications. In the brain, for example, NIC went from four more or less omnibus brain protocols to multiple dedicated protocols. Selecting the right protocol for a given patient became a new radiologist responsibility at NIC, but the extra time was more than made up for in reduced scan times for many patients.


"'Mrs. Jones' still might need 90 minutes in the scanner, but the next patient might get a 15-minute protocol," he says. "We would save two, three or four minutes per protocol in many cases. In others, we would spend more time than usual, but the key is we're not spending more time on everyone."

Measuring progress is watching blue bars grow

The graphic product of the Utilization Services tool allowed NIC to easily measure the impact of their interventions on system use.


"We can take a snapshot of time periods from an hour, to a day, to a week, to a month," he says. "We looked at our graph in the beginning and then periodically to see how our solutions have affected system utilization. Finally, we are able to stop guessing about our efficiency, and start knowing about it."

Dr. Orrison reports that the practice changes his team has implemented have increased system utilization to 75 percent, with 90 percent utilization the ultimate goal.

He credits the explicitness of the Utilization Services tool's graphic interface as compelling the changes that NIC adopted. "The utilization times are presented in a way that makes the inefficiencies and discrepancies between different patients so obvious that the possible solutions overwhelm you," he says. "I am sure there are more things we can do to increase efficiency, but it was almost like a flash flood of solutions."



Comparison of initial Intera 3.0T system utilization (left column, Sep. 20, 2006) and utilization after implementation of improvement solutions (right column, Apr. 3, 2007). These figures show actual system use during one day; the graphs present minute-by-minute scanner activity from 0:00 am to 24:00 pm, thus providing an instant view of scanner usage. Gray areas represent inactive time and waiting time, blue areas represent patient preparation and actual scanning.



These Total Examination time graphs show accumulation of scan time and inactive time for each hour in the day. The initial situation (left , Sep. 20, 2006) is compared to system utilization after implementation of solutions for improvement (right , Apr. 3, 2007). After improvement the ratio  of active time (blue) vs. inactive time (gray) is dramatically improved.



One idea to sustain NIC's improvements even arose from the utilization management program - bonuses based on efficient scanner use, he adds. "This will give the technologists some incentive to keep this going. It will be a very objective measurement of the employee's ability to effectively utilize the scanner."

NIC's pilot-project experience with Philips' Utilization Services will change into an ongoing program, as NIC officials strive to see how far the software tool will take them.

"Utilization Services is a terrific product and I think Philips is completely on the right track," Cartwright says. "They understand the needs of outpatient imaging centers and realize that a tool like this is going to be an absolutely essential part of their overall management and operations."


"We're still hammering away at this," Dr. Orrison adds. "I'm not convinced that we've run out of ways to increase efficiency with this product, but we've made amazing progress in three months. "We'll make a lot more in the next three."

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Jan 15, 2008

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