Nuclear medicine continues to be a very important aspect of health care in the United States and throughout the world. TechNation examines the future of the market and the best approaches to maintain and upgrade these devices with a roundtable Q&A discussion.
The experts on the roundtable panel are Michael Eaton, Field Service Engineer at Southeast Nuclear Electronics; Danny Hamm, Vice President of Sales, InterMed Nuclear Medicine Services; Nik Iwaniw, MM, RT, CNMT, Vice President, Marketing and Services, Universal Medical Resources Inc.; Eric Langsfeld, owner, E.L. Parts LLC ; Will Martinez, Director of Field Service/Global Medical Imaging; Don McCormack, Chief Executive Office, Southwest Medical Resources; Josh Nunez, Molecular Imaging Product Manager, Block Imaging; and John Shaw, Service Engineer, Northeast Electronics Inc.
Q: What are the latest advances or significant changes in nuclear medicine?
Eaton: Although not a new concept, hybrid modalities such as SPECT/CT are gaining popularity in clinics and hospitals. Many of these systems are approaching the end of their OEM warranty, if they haven’t already.
Hamm: The latest advance that has the most significant impact on nuclear medicine is Wide Beam Construction software. It has the ability to acquire images in about half the time as standard software, enables the study to be performed with half the dosage of isotopes, or both at the same time (depending on the version and type of software).
Iwaniw: Not unlike other imaging modalities, technical advances in nuclear medicine continue to be introduced to improve clinical decisions for physicians and patients. Some of these are related to improved SPECT, SPECT/CT, and PET/CT systems. In addition, due to budget restraints, imaging providers are searching for less costly nuclear imaging system alternatives. However, advances in creating new disease specific radiopharmaceuticals will be a driver for nuclear medicine utilization. Also, Appropriate Use Criteria (AUC), radiation dose reduction, and maintaining a consistent supply of Mo-99 for Tc-99m will impact the future of nuclear medicine.
Langsfeld: As a parts vendor, we have noticed a rise in the demand for parts on the hybrid systems of SPECT/CT and PET/CT. As more of these systems are coming off OEM warranty, the third-party market has stepped in with service and support offerings for these systems while raising the demand for quality used or refurbished parts and technical support.
Martinez: Circuits are getting smaller, so things can be packed into smaller, thinner packages. There are digital detectors, but the usable yield of producing CZT crystals is less than 20 percent per batch. The size of the good yield is still only for small FOV (Field of View) detectors. Overall resolusion has not significantly improved for the past 10 plus years. If you check detector specs between a Siemens eCam and the newest Symbia, there is NO improvement. Only post processing has improved with half time imaging being the chief advancement.
McCormack: Nuclear medicine has changed over the years in the way it handles data. On the hardware end of things, different types of collimators, hybrid imaging, and workflow enhancements have allowed health care providers to deliver information to patients in ways never seen before. New radiopharmaceuticals are also in the pipeline that will potentially offer clinicians better ways to analyze disease both qualitatively and quantitatively.
Nunez: One of the main advances in nuclear medicine is the introduction of Cadmium Zinc Telluride (CZT) detectors by Spectrum Dynamics and later by GE. These are faster and have higher resolution than previous sodium-based detectors. They are also very expensive. Another significant advancement in nuclear cameras is the spread of hybrid imaging in the form of SPECT/CT. It broadens the ability of nuclear cameras into areas where the hybrid study can stand alone and cover more areas of diagnosis.
Shaw: Nuclear medicine has seen quite a few changes over the past few years mostly by adding another modality (hybrid) to the SPECT system such as SPECT/CT. PET imaging, also a form of nuclear medicine, has made many advances in oncology and cardiology. The basic gamma camera has not changed much in the past 10 years.
Q: How will those changes impact the nuclear medicine market in the future?
Eaton: According Dr. Schwaiger of the Technical University of Munich, the border between the imaging modalities “will have disappeared” by 2020. The trend seems to be shifting away from a modality-specific focus, onto organ or disease specific groups. This will certainly impact the parameters in which imaging equipment is purchased and utilized.
Hamm: The main benefit to physicians, hospitals, and other medical providers is that it allows a facility to perform studies on more patients within the same timeframe. This enables the facility to increase the amount of revenue generated without increasing any additional costs or time needed to perform the studies.
Iwaniw: Most predictions forecast growth in the nuclear medicine market. A favorite saying of mine is “The best way to predict your future is to create it.” In order to better create our future, proactive measures such as AUC that communicates to CMS about cost-effective treatment algorithms, especially for nuclear cardiology, are intended to justify reimbursement. The aging population will also support the effective outcomes provided by nuclear medicine imaging procedures. Budget restraints support the sale of reconditioned systems that can be upgraded in the future.
Langsfeld: There will always be a market for used and refurbished parts whether it be strictly nuclear medicine or for a hybrid system. Users of the equipment are always looking for a less expensive but quality option to support their equipment. While many facilities are moving toward hybrids, there are still several facilities that do not have the budget or need for them. So, the standalone nuclear market will still exist.
Martinez: When CZT yield and size improve, detector overall size will significantly decrease. The digital nature may open more possibilities with the use of ever improving software control. The half time imaging software algorithm will likely improve in sync with the acquisition control software.
McCormack: As nuclear medicine becomes more efficient and is able to offer greater information, doctors will continue to turn to this modality for the answers they need. Nuclear medicine has been and always will be the only way to image physiology, or functional process. With the ability to quantify tumors, for example, we are able to better understand where the patient needs to be in the treatment process. No other modality can really do this like nuclear medicine.
Nunez: Widespread use of the higher-resolution detectors will bring the unit cost on these down. In addition, the higher resolution and higher sensitivity will enable nuclear cameras to expand into studies and uses that have been traditionally part of the domain of PET and PET/CT. It can’t replace these other modalities, but is becoming a viable alternative in some circumstances and markets.
Shaw: Nuclear medicine has been considered a dyeing modality since I entered the field in 1982. First the word was that CT will do the studies that nuclear formally did, then it was MRI then it was PET. Nuclear medicine departments still seem to be an important modality in spite of the death that I had always been warned about. In the future, the basic gamma camera will still be around but the hybrid systems seem to be the future at this point.
Q: How will new technology and other advances impact the maintenance of nuclear medicine devices?
Eaton: From a maintenance standpoint; hybrid systems will require a broader knowledge in theory of operation in what may have previously been foreign territory. From an end user standpoint, your cost of ownership analysis may require some revaluation.
Hamm: Nuclear cameras are more software-driven than ever before. The newer cameras have fewer moving parts, are more accessible to service from an engineer’s perspective, and allow for more detailed and thorough diagnostics through the workstation/computer; minimizing some of the mechanical diagnostic aspects, which are generally more time consuming and costly.
Iwaniw: They shouldn’t drastically affect the maintenance standards that are already in place. It will be vitally important that thorough preventive maintenance is performed on a regular basis. The technology for SPECT cameras will tend to be geared toward software technology versus actual camera technology, which would require clinical engineers and field service engineers to be more computer savvy.
Langsfeld: Preventative maintenance has always been and will continue to be very important for any system. PM checks are recommended on all systems, and the OEM guidelines should be followed no matter who is servicing the machine. Some facilities try to save money by ignoring PM, but in the end, it will lead to more costly repairs.
Martinez: The smaller lighter overall size of the machine will allow for better mechanical reliability of the gantry system. The smaller electronics will be more integrated. Fewer PCBs will allow for faster troubleshooting. Software will be the chief troubleshooting aid.
McCormack: As the technology advances, the local service engineers need to be trained so that they can repair the equipment. Workflow enhancements like automatic quality control are fairly new concepts in the industry and bring with it the need to have a little more knowledge of radiation safety when handling radioactive sources. In addition, these systems are becoming more advanced mechanically which means there is more potential for things to go wrong.
Nunez: Brand new technologies may take a while for the knowledge and access to spare parts to trickle down from the OEM. CZT detectors are a case in point. We have not seen many nuclear cameras with the newer detectors on the market. We have no parts for them. This will change in a couple of years as systems are harvested for parts and the engineering expertise on them grows. On the other hand, for hybrid technologies like the SPECT/CT, we have engineers familiar with both halves of that product, so there is no delay in being able to service and maintain them.
Shaw: Gamma cameras are now driven by computers and software. Many manufactures will boast about repairs done remotely and some repairs can be done this way. Detector tuning and maintenance is all done through software programs to tune the PMTs and align the offsets in the detector. The service engineer of the future will need to be more computer savvy but the electromechanical portion of the system will never go away so the engineer needs to also be a mechanic.
Q: How can a facility with a limited budget meet its nuclear medicine needs?
Eaton: If a facility is looking to add or replace a nuclear medicine system, I suggest researching third-party refurbished systems. A reputable company can provide OEM quality systems and service at a fraction of the cost. Ask about renting/leasing as well. For a facility looking to maintain a department on a budget, a bi-annual preventative maintenance schedule is your best ally. Skipping one or two PMs may save a little in the short term, but this practice usually ends up costing more than you save.
Hamm: Initially they should buy a reconditioned camera from a reputable company. This will save significant dollars on the front end, and a properly reconditioned camera should come with the same warranty as a new camera. In addition, adding half-time imaging software will allow the facility to maximize patient throughput on the days they are scanning patients. Also minimizing the indirect costs by having a quality service provider will maximize the overall efficiency of the nuclear program. By performing thorough preventative maintenance, offering quick response times, and having competent engineers, the camera will be running and generating revenue a larger percentage of the time. This equates to scanning more patients and minimizing the need to reschedule studies.
Iwaniw: Limited budgets support the purchase of refurbished/reconditioned nuclear medicine systems. It is important that the reconditioning process is comprehensive in order to provide a camera system that an imaging provider can rely on for many years. Flexible financing options are also important for the imaging provider to be able to afford updated camera systems.
Langsfeld: Making sure the facility is purchasing the correct system for their needs is important. When first purchasing a system, everyone affected by the transaction should be involved to ensure the correct system and options are included to meet the current and future demands without buying unnecessary equipment or purchasing something that won’t support the needs. Finding a reputable service and parts vendor is also very important in maintaining a budget. Based on useage and availability of parts, discussing service contract options or time and material support with your vendor will be helpful.
Martinez: Easy. Buy reputable reconditioned equipment with updated processing workstations. As mentioned earlier, there has not been any significant improvement in acquisition resolution. New systems are great if you can afford it. It does perpetuate what we are doing in the third-party arena and we need to appreciate that OEMs are continually releasing new products. If you are on a limited budget, a good reconditioned system will give you the same diagnostic quality.
McCormack: Well, that’s where we come in. We can offer these same products to health care providers at a price point that is lower than that of the OEM. These systems have previously been used by other hospitals but we remove them, replace old and damaged parts, and re-install them into other facilities. With the care that third parties provide, these devices will continue to produce the diagnostic images that physicians require for a long time.
Nunez: Consider used or refurbished equipment. Nuclear medicine is a great place to save money in your imaging facility. There are several high-quality companies in America that can provide refurbished or reconditioned nuclear cameras and SPECT/CTs that will meet or exceed OEM specifications when new.
Shaw: Many rural facilities are looking for good quality refurbished equipment to fulfill their nuclear medicine needs. This has been a great option for hospitals and clinics for over 40 years. Most manufactures have moved to hybrid systems that are very expensive and will leave the small hospitals and clinics out. You don’t need a hybrid SPECT/CT system to do general nuclear medicine procedures. There are also fusion programs that allow the user to overlay one modality over the other. Hybrid systems are not needed to do this.
Q: What do you think TechNation readers need to know about purchasing and servicing nuclear medicine equipment?
Eaton: Don’t allow yourself to be over sold. It is posable to purchase quality equipment and produce desirable results without breaking the bank. A good service/sales company should be able to provide viable solutions at a reasonable cost.
Hamm: Find a camera that fits their specific needs and a service provider they can rely on. For example, if a facility only performs cardiac studies, they would be better off going with a designated cardiac camera as opposed to a larger variable-angle system. They take up less space, use less power, cost less to service, and tend to be more reliable. Though both cameras perform the same function, one is much better suited for a specialty practice, and they want to partner with a company that has their best interest in mind. When they have a service agreement, the practice should be confident that their service provider will effectively maintain their equipment so they don’t have to worry about that aspect of their business and they can focus on patient care.
Iwaniw: They should look for a camera/service provider who is able to provide effective, timely service, has a ready inventory of parts, and can offer flexible service contract options. They should also be partnering with nuclear medicine camera providers that can offer flexible financing options in order to meet their budgetary needs. They may wish to take into consideration the provider’s ability to offer training for in-house clinical engineers.
Langsfeld: While price is important, it should not be the first deciding factor. I would recommend asking questions to ensure you are getting the best value for your equipment, service and parts. Any good vendor will take the time that is necessary to make certain you are getting exactly what you need the first time.
Martinez: When purchasing equipment, whether new or reconditioned, service options are imperative. Your unit will require repair and general maintenance no matter what. Be sure that you are not limited to a make/model that has a limited install base.
McCormack: Purchasing capital equipment is a big deal. In many cases, the room needs to meet specific requirements, and the equipment and maintenance throughout the life of the system can be quite costly. I suggest doing your research on the camera and serviceability of the system you want. The big equipment manufactures all provide ways to acquire patient data but it’s the bells and whistles that tend to set them apart. These bells and whistles can, in some cases, add challenges to the way the systems are serviced so these things need to be looked at.
Nunez: If you are not looking at an almost unlimited budget or a large grant to buy a nuclear camera or SPECT/CT, consider looking on the secondary market. We are seeing a good number of quality used systems coming out as first-tier establishments order the latest and greatest.
Shaw: TechNation readers/purchasers should start with the facility’s radiology manager and nuclear medicine technologists. These are the front line people using the equipment every day and know what is available for procedures and what their referring physicians are requesting. Service can be a tough spot for the clinical engineer. Many ISO companies will offer training and some sort of “first look” program that would allow the facility to save money. It is often stated, by the biomed engineer, that nuclear medicine is a real thorn in their side. The training is great if you work on the system regularly but is easily forgotten if you don’t get to touch the system for a year or so.
Q: What are the most important things to look for in a reputable third-party nuclear medicine provider?
Eaton: Knowledge of your specific system(s), immediate access to inventory, and enthusiasm. A dazzling website and/or expensive advertising does not necessarily translate into quality service. Take the time to have a conversation and ask questions. Personally, I love what I do, and enjoy discussing it with customers and prospects alike.
Hamm: How long they have been doing business, and how much of the camera reconditioning, relocations, installation, and service is performed with their own engineers. Whether or not they have a Radioactive Materials License; this is important when reconditioning cameras so they may be tested with sources to ensure all parts of the cameras are functioning properly. Lastly, I would say to check customer references; reach out to some facilities who have used the third-party for service and ask them about their experiences. All cameras will inevitably go down at some point, it’s how prompt, professional, competent, and thorough the service provider is when things do go down that separates the top third-party companies from the rest.
Iwaniw: Technical competency with your system, readily available parts, response time, technical phone support capability and accessibility, comprehensive refurbishment process, and customer service culture to name a few.
Langsfeld: Seeking referrals is a good start to finding out the reputation of a provider. You can also research the company online and see if there have been any issues or concerns reported on forums or with the Better Business Bureau. But most importantly, do not be afraid to ask questions; if they are unwilling to provide information or take the time to address your concerns, then they may not be the right fit for you.
Martinez: Many third-party providers do all major OEM models that are highly installed. While this is true, most providers have a bread-and-butter line that they do best. Find out what that is.
McCormack: Knowing that your service provider has an adequate number of engineers with the knowledge needed for servicing you equipment is probably the most important. There are a lot of companies out there claiming they can service nuclear medicine, but many will only manage your asset without having direct knowledge of the equipment. Parts availability, facilities, and strategic proximity to their supply chains are also important things to think about.
Nunez: We tell our customers that the nuclear medicine world is very small. You can’t run from a bad reputation. You want to work with someone who has the resources to fix things if they go wrong. Things can happen to any system, but can your nuclear camera provider cover those if it ends up being a loss for them? You need to know that they aren’t just willing to provide your imaging needs, but that they are capable of supporting them as well.
Shaw: Third-party organizations are always required to perform better than the OEM, one slip up and you’re out. OEMs are almost never thrown out unless it is for saving money. The best reference is other facilities that have used the ISO and can give a recommendation. Nuclear medicine is a very small community, almost all technologists know each other and this would be the best way to compare notes.
Q: How can purchasers ensure they will receive the necessary literature and training tools when purchasing nuclear medicine devices?
Eaton: Don’t be afraid to ask questions and be engaged. Nobody knows your business like you do. Be sure to communicate your needs and expectations before, during, and after the buying process.
Hamm: Any reputable company should provide the purchaser with all applicable literature relating to their camera and should be able to offer detailed applications training. The better the nuclear tech knows how to operate the camera, the better it is for everyone involved, so that should be a priority of the company selling and servicing the equipment.
Iwaniw: Service manuals can be a challenge as these are generally proprietary. General system operating manuals and software operating manuals should be part of the system purchase (these can be hard copy for older systems and within the software for newer systems). I would encourage the purchaser to inquire into whether the third-party provider offers formal training classes.
Langsfeld: When purchasing a system, always make sure to request the operator’s manuals and software disks, if applicable. Ask about training and support offerings to ensure a level of comfort for use. If you do encounter a problem, you want to make certain that the seller will be available and willing to help you seek resolution.
Martinez: The literature is generally available from the original point of sale OEM. There is no lack of highly capable applications specialist in the third-party market. The selling third-party company should be able to answer this upon the initial consult.
McCormack: Service is about having proper knowledge of the equipment. Purchasers need to make sure they are buying from companies that have the resources at their disposal and not just a middleman. All the systems we sell and service come with customer manuals and if there are ever questions, we offer tech support over the phone as well as onsite training once systems are installed.
Nunez: Manuals, system demonstration, and extensive applications training are all available with any system we sell. However, we find most customers don’t need a lot of training. If we schedule three days of applications training, many sites will feel comfortable in two days.
Shaw: Facility purchasers should require training and technical manuals when ordering their systems. If the OEM or ISO will not provide these items then they should look at another vendor. A large facility will have much more clout than the small facility and that can be quite a hurdle for the small group. Finding leverage in order to get the vendor to comply is always a challenge. Don’t rule out ISO companies when looking at new systems. Many ISO groups offer new cameras along with high-quality refurbished systems.
Q: What else would you like to add or do you think is important for biomeds to know about nuclear medicine devices?
Eaton: Listen to your technologists! These men and women spend more time with this equipment than anyone else. Their input is a valuable resource that all too often remains untapped.
Hamm: Nuclear cameras are a different animal than other diagnostic imaging systems, so find a company with a long-standing, positive reputation within the industry so they have confidence the camera will be maintained and function as efficiently as possible. Find a full service company that can perform all aspects of nuclear medicine services with their own engineers and also has the same goals and focus of taking care of their customer. Once they find a company they trust who is like-minded in the delivery of quality service, together they can exceed the customer’s expectations and ensure a long-term, mutually beneficial relationship.
Iwaniw: Nuclear medicine systems remain a technical service challenge for biomedical engineers/clinical engineers. With the evolution of clinical engineering departments becoming responsible for the budget to maintain their nuclear medicine systems, it is extremely important for them to develop a mutually beneficial partnership with their third-party service provider. This should be a collaborative effort to work together for cost effective and reliable system maintenance.
Langsfeld: Finding the right vendor is very important. From your first part purchase to a service repair or full system integration, seeking a partnership is critical. Every system has differences, and depending on what is needed for the repair, re-tuning and calibrations must be performed by a trained and qualified engineer to guarantee your system remains up and running.
Martinez: Nuclear medicine requires the most patience of all the imaging modalities. Sometimes the bad result doesn’t come for two or three hours. The usual remedy is to just start over. Appreciate your service engineer.
McCormack: I would say that these devices are quite different from other modalities in radiology. The physics are quite different from one device to the next. In my experience, most engineers don’t understand or even like nuclear medicine. That’s why we are here to provide our expertise.
Nunez: I think most biomeds are comfortable with nuclear camera equipment in general, but if their facility has ever purchased a nuclear camera from an unqualified vendor then they likely have some concerns about second hand equipment. It’s critical to find a reputable vendor.
Shaw: Clinical engineering departments should consider training, applications and technical phone support at the top of their list. If the clinical engineering department is big enough to take on the nuclear department it is best to train one person so he is proficient and will be able to cross train other engineers. Training is out there and many companies, especially ISOs, are very willing to work with clinical engineering departments in order to get in the door even if it is only a small piece of the pie. Once in, and the vendor can gain the confidence of the technologist and the clinical engineering department, this can make for a win-win relationship and will make the job for the technologist and biomed engineer much easier if they have a good source to contact. Applications support is always important for the nuclear medicine technologist.
