3D Imaging in Radiology

Transcription

1 3D Imaging in Radiology Gordon J. Harris, Ph.D. Director, 3D Imaging Service and Radiology Computer Aided Diagnostics Laboratory, Massachusetts General Hospital Director, Tumor Imaging Metrics Core Dana Farber/Harvard Cancer Center Associate Professor of Radiology, Harvard Medical School

2 Acknowledgements Dr. James Thrall, Chairman Radiology, MGH Dr. R. Gil Gonzalez, Chief Neuroradiology, MGH 3D Imaging Service Staff: Jennifer McGowan, Peggy MacWilliams, Sally Pinho, Kate Weiss, Joan Beaudoin, Julie Della Monica, Jane Kelley, Fresnel Josaphat, Anthony Ranson, Shirley Thurston, Jonathan Lombardi, Trinity Urban, Dierdre Pierce, Joyce Miller, Bill Hanlon, Jon DeVries, Hiro Yoshida, Wenli Cai, Janne Nappi, Vadim Frenkel

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4 3D Imaging Overview Goals of 3D Imaging Service 3D Imaging and Clinical Benefits 3D Imaging Service at MGH Clinical Exam Volume Staff Workflow 3D Billing and Reimbursement

5 Goals of 3D Clinical Service Integrate Computer Aided Diagnosis (visualization, quantitative analysis) into routine clinical workflow Bridge research and clinical applications to migrate new technologies into clinical practice

6 3D Imaging Axial images are stacked into a threedimensional volume Stacked Axial Slices 3D Volume sjn/mgh

7 Image Processing Techniques Multi Planar Reconstruction (MPR / MPVR) Oblique and Curved Reformat MIP (Maximum Intensity Projection) Shaded Surface Display Volume Rendering Endoluminal Views (Virtual Colon, Bronch, Vessels) Functional Imaging CADx: Segmentation, Quantitation

8 2.5 mm 1.25 mm

9 MIP Rendering Maximum Intensity Projection Displays the pixels of highest intensity along a ray Useful for vascular anatomy sjn/mgh

10 Orthopaedics: Volume Rendering (VR)

11 Neurovascular Imaging: VR Curved

12 CT Bronchography: Endoluminal See-Through

13 Neurovascular CTA/MRA: VR MIP

14 Cardiac CTA: Normal 3 CABG

15 Functional Analysis - Image pixels derived from a function of changing signal over time CT/MR Perfusion fmri

16 Functional CT Perfusion CBV CBF MTT

17 Functional MR Perfusion CBV CBF MTT

18 Functional MRI (fmri)

19 Computer-Aided Segmentation

20 Virtual Hepatectomy Semiautomated segmentation Total Volume = cc s

21 Virtual Hepatectomy Transplant segment Define surgical plane Sufficient volume for regeneration Left Lobe segment cc s

22 CADx: Automated Segmentation: VR MIP

23 CADx: Brain Tumor Volume

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25 Tumor Volume BRIGHT DARK TOTAL

26 CADx: Breast Imaging R2 Mammogram Image Check MR w/ registration/subtraction QuickTime and a decompressor are needed to see this picture.

27 CT Angiography (CTA) QuickTime and a Microsoft Video 1 decompressor are needed to see this picture.

28 CT Urography (CTU) CTA/CTU: non-invasive replacement -- Catheter Angiography PLUS IVP

29 Clinical Benefits of 3D Radiology More comprehensive and realistic views of patient Faster, more confident diagnoses and treatment planning decisions Reduced need for exploratory surgery Minimize surgical invasiveness and operating room time; reduced damage to healthy tissue

30 3D Imaging Service at MGH Clinical computer visualization for routine clinical use; 3D on request. Fast turnaround, full-time technologists Full integration with hospital PACS and information, billing systems Currently, over 2500 cases processed per month

31 3D Imaging Service Staff (13 FTEs) Director Operations Manager Administrator/Billing Coordinator Technical Staff (2) 3D Technologists (5) Image Analysis Specialists (2) 3D Ultrasound Technologist

32 3D Imaging Service Hardware and Software at MGH 5 GE Advantage Workstations 5 Vital Images Vitrea Workstations Tera Recon Aquarius Workstation and NetServer 2 Voxar Workstations 2 LINUX Computers with MedX/VolumePro for fmri Mirada Fusion7D Workstation for image registration 3 GE LogiqWorks for 3D Reconstruction of US AGFA PACS Service Station, and RadWorks PACS Materialize SimPlant/Master for Dental Implant Planning MMS Preview LINUX Server LINUX DICOM Server, 7 PCs, 2 Macs

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34 MGH 3D IMAGING SERVICE: Daily Average Volume by Month October November December January February March April May June July August September FY' FY' FY' FY' FY' FY' FY' FY'

35 3D Imaging Service Clinical Workload at MGH 120 Exams per day processed 30 per day MR Angiography (MRA) 30 per day CT Angiography (CTA) 30 per day other CT and MR exams 30 per day Ultrasound Radiology Sub-Specialty breakdown 50% Neuroradiology 20% Vascular Radiololgy 30% GI/GU, Chest, Breast, Bone, Pedi Radiology 20% of all MR,US Exams: ~16,000/80,000 per year 10% of all CT Exams: ~ 12,000/120,000 per year

36 PACS Gateway AGFA/PACS Original Scan Original CT/MR scanner Original Radiologist View Station AMICAS WEB Server Original Referring Physician s s Desktop PC WEB Browser

37 PACS Gateway AGFA/PACS Original Scan Original 3D CT/MR scanner Original 3D Radiologist View Station Original 3D AMICAS WEB Server Original 3D 3D Workstation Referring Physician s s Desktop PC WEB Browser

38 Combine Combine Clinical Need Clinical Need with with Products Products Billing Billing Codes Codes PACS PACS Routing Routing Scan Scan Protocols Protocols 3D 3D Protocols Protocols Referral Referral Protocols Protocols Implement OR Identify Clinical Clinical Need Need Evaluate Evaluate Clinical Clinical Products Products New New Product Product Evaluate Evaluate Clinical Clinical Need Need Billing Billing Compliance Compliance Clinical Clinical Workflow Workflow

39 Imaging Protocols Part of departmental scan protocols Billable Service

40 Billing and Reimbursement: 3D Add-on Code CPT # 76377(6) for 3D reconstruction Billed in association with Primary CT/MR/US code Requirements for Reimbursement: Part of Departmental Protocol, Physician Notification By specific request from physician Positive finding by radiologist, requiring further views Processing on FDA approved software

41 Billing and Reimbursement: 3D Add-on Code -- How to bill: TC component -- if billed by Hospital: Billed under HOPPS, APC 282 Reimbursed by Medicare at $95 (Nat l Avg, 2007) TC component -- if billed by non-hospital: Billed under MPFS (RVU-based) Reimbursed by Medicare at ~$113 (Nat l Avg, 2007) Used if non-hospital imaging center, or 3D done by P.O. Split or Global billing Prof. (-26) reimbursement ~$41

42 Billing and Reimbursement: CT and MR Angiography (CTA/MRA) Billed prior to 2001 with CPT # New CPT codes in 2001 for CTA CTA and MRA now include post-processing 3D processing no longer separate charge for CTA/MRA PROBLEM: CTA was reimbursed same as CT No additional reimbursement for added time, equipment We have achieved changes from Medicare new APC in 2003 for CTA (need to improve charges) Increased 2003 RVU TC reimbursement

43 Billing and Reimbursement: CTA Problems Continue!! Even with CMS changes in CTA, problems remain APC Reimbursement set relative to claims data Only 40% of hospitals charge more for CTA than CT!! (Source: 2001, 2002 CMS claims data) Most hospitals charge less for CTA than CT!! - CMS example: Hospital Y charged ~4X for CT ($1,392) vs. CTA ($377) Impact: Reimbursement for CTA less than CT

44 Billing and Reimbursement: CTA Charge Recommendations Prior to 2001, CTA was equal to CT PLUS 3D! 2001 reimbursement was $114 higher for CTA Hospitals must set charges accordingly Review Chargemaster and revise CTA charges relative to CT Charges for CTA should reflect sum of charges for CT (w/&w/out) plus charges for 3D (76375) Example: If CT charge is $1200, and if 3D charge is $400, CTA charge should be $1600

45 Impact of New Technologies on Radiology 3D Visualization enables faster, more confident diagnoses and treatment decisions Quantitative analysis and CADx can provide more accurate, reliable treatment planning, staging, and assessment Improved patient care, increased clinical confidence, reduced time, cost, and invasiveness

46 Vision for the Future of 3D and CADx Services Scale Up Services to Support Needs of Many Hospitals and Imaging Centers Most Facilities Lack Resources and Expertise to Implement In-House Solution Off-Hours Coverage Difficult Use Advances in Networking and Communications to Centralize Services Expand CADx and 3D Services Advanced Core Lab

47 Any Thank Questions? you!!!