HealthManagement, Volume 16 - Issue 3, 2016

Countries around the world have different relationships to advanced ‏diagnostic imaging in the out of hospital (outpatient) environment. In ‏Australia and Italy, it is not uncommon to find imaging centres in shopping ‏malls, a concept which is anathema to both the United Kingdom & South ‏Africa. A shift from hospital based imaging services to a mixed model of ‏both hospital and outpatient centre imaging is inevitable in the current ‏environment. The reasons for this can be explained from a financial, ‏operational & patient perspective.


Hospitals have traditionally been bastions of capital intensive resources ‏such as computed tomography (CT) and magnetic resonance imaging ‏(MRI); in state healthcare systems it is most common for hospitals to have ‏both the resource and the expertise to run both inpatient and outpatient ‏imaging services. In the USA, greater state reimbursement for imaging ‏taking place in a hospital environment has incentivized the status quo. ‏Indeed, imaging remains important to the bottom line of many institutions, ‏subsidizing less profitable service lines.


However, providing both inpatient and outpatient imaging within hospitals ‏can prove extremely inefficient. Operationally, scanners may be tied up ‏for considerable periods with challenging inpatient requirements. Even ‏with dedicated ‘outpatient scanners’ it is not uncommon for unexpected ‏downtime to lead to delays in scheduled outpatient imaging. Overheads ‏and fixed costs are also greater within a hospital making a dedicated ‏outpatient diagnostic imaging centre more efficient both financially and ‏operationally.


But do these centres provide advantages for the patient? I would argue ‏they do, both in terms of convenience, emotional experience and in ‏some cases, cost. Bringing imaging closer to the patient is now eminently ‏possible. A centralised booking service can offer a choice of locations ‏within a network, providing flexibility both in time and geography. ‏Establishing an imaging hub to service family doctors or specialist ‏physicians in an outpatient setting also allows potentially less travel time ‏between referral and scan.


The ability to park is an undervalued commodity. Outpatient imaging ‏centres are usually designed with this in mind, whereas parking space is ‏often the first area cannibalized by hospitals expanding inside a limited ‏geographical footprint. Additionally, there is no reason why outpatient ‏imaging centres need to look, or feel, like hospitals. The design concept of ‏modern imaging centres can be more geared around patient experience ‏and workflow, designed to reduce anxiety. Finally, cost savings achieved ‏in an outpatient setting may be passed on to the payer. In the case of ‏private patients, this may mean a direct saving to either the patient or ‏their insurer.


The development of outpatient imaging centres in many countries has ‏often been led by entrepreneurial Radiologists who own and operate the ‏imaging equipment. But this environment is becoming more challenging. ‏Declining reimbursement, alongside increased demand, forces improved ‏efficiency, driving consolidation to larger and more efficient players such ‏as Affidea in Europe and Radnet in the USA.


Surprisingly, arguments against outpatient imaging centres are often ‏made by clinical staff. There is a perceived loss of control, and concern ‏that Radiologists out of hospital will no longer be part of the multidisciplinary ‏team or be available to answer clinical questions.


As those countries with developed outpatient imaging services ‏understand, the answer is not binary. Radiologists will always remain an ‏essential part of the on-site hospital team. Not only has there been an ‏exponential increase in the requirement for inpatient imaging as a central ‏role in the diagnostic pathway, but inpatient imaging is more and more ‏required to guide intervention – both diagnostic (biopsy) and for real time ‏intervention, vascular and radiation therapy in particular.


Another argument against the outpatient centre is that Radiologists must ‏be co-located with scanners in order to correctly protocol and oversee ‏the scans, as well as contrast administration. However, in the last decade ‏there have been massive and well documented technological changes – ‏from centralized radiology information systems (RIS), fully digital picture ‏archiving and communication systems (PACS), to voice recognition and ‏the move towards the electronic patient record. More recently, there ‏have been developments in smart protocolling that remove the need for ‏individual scrutiny of every request, as long as there is sufficient clinical ‏detail and a clear clinical question. This coupled with senior technicians ‏(Radiographers), able to operate independently, have allowed the ‏development of satellite outpatient imaging centres that do not require ‏the full time presence of a Radiologist. Although there must always be a ‏Radiologist available remotely to view scans, answer clinical questions ‏and communicate urgent results, contrast may be administered under ‏supervision of a non-specialist doctor with resuscitation training.


This is of great benefit to patients in remote regions. Radiologists no ‏longer have to be single handed, or be expected to have expertise in ‏every area of Radiology. Reporting hubs offering subspecialty expertise ‏and even home-reporting are massively more efficient, with reduced ‏interruptions, improved workflow and smart worklists. Of course this is ‏contingent upon receiving support by an adequate IT infrastructure. ‏Fear of dissociation from clinical teams can be allayed by regular clinical ‏interaction at meetings either in person or by video conference.


These factors all contribute to an inevitable rise in outpatient imaging ‏centres even in countries where the penetration is currently low. The ‏continued rise of the outpatient imaging centre is inevitable in an era of ‏value based healthcare and in an environment where patient experience ‏plays an ever increasing role in how services are delivered.