Medical Solutions Dec 08 - Breast Cancer-

Medical Solutions The Magazine for Healthcare Leadership

December 2008

Breast Cancer Where are we – and where are we heading?

Cardiology Diagnosis in the Emergency Room

What’s the difference between imaging and imaging greatness??

Ask the Ultimate Power in Imaging. Every year Siemens provides a spectrum of new imaging systems that enhance diagnostic precision. With syngo® the first unified software interface for all imaging modalities was delivered. Tim® technology revolutionized MRI, and Dual Source CT continues to drive new clinical possibilities. Talk to us to experience these innovations and new groundbreaking advancements in imaging excellence. www.siemens.com/answersforlife +49 69 797 6420

Answers for life. A91CC-9016-A3-1-7600

Editorial

Advancing Patient Care The growing and aging population is one of the most significant challenges facing healthcare providers. This trend will drive an increasing demand for healthcare services, particularly for diseases that occur later in life and are costly to treat. In many situations, healthcare delivery has not evolved to the point where individual patient’s needs are considered. Our goal at Siemens Healthcare is to enable this high-quality, patient-centered approach by integrating imaging, laboratory diagnostics, and healthcare IT, creating seamless and significantly improved workflow efficiencies. Take prostate cancer as an example. Typically, if a clinician wants to clarify whether symptoms are signs of prostate cancer, he or she, in addition to a physical exam, would order a blood test to measure Prostate-Specific Antigen (PSA). A high PSA level is considered to potentially be caused by prostate cancer. Different PSA markers have to be combined and put in relation to each other to identify men who might show an elevated PSA, but who, in fact, have a low risk that this PSA value is a result of prostate cancer. Also, measuring PSA at just one point in time is not sufficient. When the patient’s PSA levels indicate possible prostate cancer, a biopsy needs to be performed. The traditional method

involves some measure of patient discomfort, and possibly anxiety, as a clinician extracts tissue from different locations for diagnosis. Ultrasound, however, allows for an image-guided biopsy, which enables the physician to target suspicious areas for extraction, reducing patient discomfort, long-term complications, and the amount of time needed for the procedure. Should the biopsy yield a positive result, molecular imaging biomarkers enable the localization of metastatic cancer cells in the body. And, Siemens REMIND clinical decision support software can help ’rule out’ other factors that might lead to higher PSA results, but not automatically to prostate cancer. When this solution is applied holistically, up to 50 percent of such misleading diagnoses can be avoided, saving time and money and increasing patient comfort and confidence. An estimated US$5 billion can be saved annually in the U.S. alone by applying measures to avoid unnecessary procedures and interventions.1 With our recent investment in laboratory diagnostics, Siemens has become the only integrated healthcare company that can offer a complete portfolio to better

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Jim Reid-Anderson, Member of the Managing Board of Siemens AG and CEO of the Healthcare Sector

manage prostate cancer, breast cancer – as discussed in the cover story of this edition of Medical Solutions – and many other diseases throughout the continuum of care. With our broad portfolio and ongoing innovations, we are here to support your efforts in advancing patient care: enabling earlier, more efficient, accurate, and patient-friendly diagnoses and treatments. Our goal is simple: to help you save lives and offer the best possible care to your patients. It is at the center of everything we do. Siemens Healthcare provides answers for healthcare – answers for life. Sincerely,

Results may vary. Data on file.

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Personalized Medicine: Novel Imaging and Diagnostic Technologies

Cardiac Care: New Standards

Cover Story 10 Breast Cancer Back in the 1980s, a bright young student completed her PhD dissertation on MRI brain diffusion imaging. Little did she know that cutting-edge technology would someday save her life. As a breast cancer patient, she now talks about her personal experience and the needs of affected women. In addition, Medical Solutions interviewed three imaging experts around the world about how diverse imaging solutions and advanced, integrated technology are providing a new level of care for breast cancer patients.

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Essay Series: Japan

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Further Reading

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Service

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Imprint

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Med Meets IT: Project Expert Care

Training: Three Locations, One High Standard

Features 20 With a shared vision of preventive and personalized medicine, Siemens and National Jewish Health aim to develop novel imaging and diagnostic technologies using genomics, proteomics, integrated research, and clinical care.

26 To overcome claustrophobia and positioning difficulties, Clínica de Diagnóstico por Imagem relies on Open Bore magnetic resonance imaging.

30 The ARTISTE integrated radiation therapy solution helps Baton Rouge General Medical Center’s Pennington Cancer Center to rapidly and efficiently deliver radiation therapy close to home.

35 Offering better return on investment and workflow efficiency, Biograph Molecular CT – mCT – is the imaging crossover that will change the way hospitals think about integrated imaging.

38 A new cardiac care and research institute in Western Canada, the Mazankowski Alberta Heart Institute, is setting new standards of care for both pediatric and adult patients under one roof.

44 By implementing a comprehensive IT solution across the entire organization, MedCentral, a regional health system in Ohio, became a world-class institution.

50 Tissue Strain Analytics is an emerging ultrasound technology with the potential for quicker, more accurate diagnoses of tissue anomalies in the liver.

54 Cardiac biomarkers provide rapid diagnosis and risk stratification, and help to improve the quality of care for chest pain patients at South Austin Hospital’s Emergency Department.

60 Within a global training concept, Siemens Healthcare offers stateof-the-art training for customers worldwide in three dedicated training centers located around the globe.

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News

CT Scanning in a Flash

The SOMATOM® Definition Flash computed tomography (CT) scanner sets new standards in both image acquisition speed and radiation dose as the world’s fastest CT with the lowest dose ever. Like no other scanner, it can image the entire thorax in less than one second and complete a cardiac scan in one-fourth the time of a single heartbeat, with a radiation dose of less than one millisievert. “Our goal was to build the most patient-friendly CT by significantly reducing dose through faster speed,” says Sami Atiya, PhD, Chief Executive Officer of the CT Business Unit of Siemens Healthcare. “Lowest radiation dose is important to physicians and patients. It’s important to us.” SOMATOM Definition Flash utilizes Dual Source technology that consists of two detectors and two X-ray sources. This configuration, coupled with a gantry rotation time of 0.28 seconds, enables a temporal resolution of just 75 milliseconds, makes dual energy scanning possible, and allows the use of 200 kilowatts. Now, Siemens scientists and engineers have discovered how to push acquisition speeds to new levels. SOMATOM Definition Flash can scan at a pitch of above three, while still

achieving gapless z-sampling, resulting in a table speed of more than 40 centimeters per second. That is because the two detectors create two complementary data spirals that, when put together, include all the information found in a single spiral acquired at a much lower table speed. Together, these features enable lung scans in 0.6 seconds, taking the burden of breath-holding off the patients. Fast scan speeds also eliminate the additional dose penalty of electrocardiographically (ECG) gated thoracic studies, so radiologists can scan the thorax and ’get the heart for free.’ Dedicated cardiac investigations can be completed in about 250 milliseconds. But more importantly: It also reduces dose to unprecedented levels down to below one millisievert. The new features also permit pediatric scans more quickly and safely than ever before. In addition, a shuttle mode makes it possible for trauma patients to be scanned to conduct dynamic time-resolved imaging over 40 centimeters, the longest range available today. Besides the reduced radiation exposure that directly results from the high table speed, SOMATOM Definition Flash offers

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several other dose-conscious features. In dual energy scans, a new photon shield prefilters high kilovoltage X-rays, both improving material separation and substantially reducing dose, making it perfect for routine clinical use. Adaptive Dose Shielding blocks X-rays that will not be used in image reconstruction. New organspecific dose reduction eliminates direct exposure of radiation-sensitive organs, such as the breast, thyroid gland, or eye. And Siemens is looking to the future, developing iterative reconstruction techniques that promise to further reduce dose. Willi Kalender, PhD, Director of the Institute of Medical Physics at the University of Erlangen-Nuremberg in Erlangen, Germany, says, “The new scanner is a true revolution. It picks up on the well established concept of Dual Source CT but improves it in several ways. We never before dared to scan with such a low dose and such a high speed.”

www.siemens.com/ SOMATOM-Sessions-Flash

News

Large Display for Artis zee Family Following the release of the Artis zee® family for interventional imaging in radiology and cardiology in 2007, Siemens launched a new, full-color large display1 for integration with the new portfolio at RSNA 2008. The Artis zee Large Display is a 56-inch monitor that allows users to replace up to eight single monitors on the system. It provides the integration of multiple modalities on one screen for greater flexibility and enables the user to configure the screen during the procedure. The operator can choose from different screen layouts directly at the tableside of the angiography system. This enables the operator to adapt the configuration to the individual workflow

steps. Continuing the flexibility and versatility of the Artis zee systems, the product can be used for interventional radiology, interventional cardiology/ electrophysiology, and surgery, and is particularly valuable for interventional imaging in hybrid rooms as it tremendously reduces the number of monitors in the room. With its high resolution (4 x HD), the Large Display shows even the finest details. Up to 200 layout combinations and the possibility to connect at least 16 image sources and show up to ten windows simultaneously enhance imaging results and workflow in the interventional suite. Moreover, the reduction of additional displays and the option

to put other video signals on the Large Display – for instance, for monitoring other rooms, telemedicine, or endoscopy – make it a rewarding investment for the future. 1

The information about this product is being provided for planning purposes. The product requires 510(k) review and is not commercially available in the U.S.

Comprehensive MR Oncology Solutions

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syngo GRACE after every chemotherapy cycle of a patient with known breast cancer: The efficiency of therapy can be easily seen by the decreasing choline.

Within the field of oncology, magnetic resonance imaging (MRI) has proven to be one of the most effective imaging techniques. For asymptomatic and high-risk patients, MRI enables both early tumor detection and oncological staging without radiation. To support precise surgery planning, therapy monitoring, and follow-up, Siemens provides comprehensive MRI oncology solutions, going far beyond single applications and software features. In Women’s Health, the first quantitative MRI breast spectroscopy application syngo® GRACE is now also available for the 3 Tesla systems MAGNETOM® Verio and Trio. By checking relative choline concentration during therapy, the efficiency for monitoring treatment is more reliable. This may also reduce the number of unnecessary breast biopsies for the women concerned. In the field of Men’s Health, syngo Tissue 4D1, the new task card for visualization of 3D dynamic measurements, is particularly valuable for prostate evaluation. Offering two evaluation workflows – standard curve evaluation or a pharmacokinetic model – syngo Tissue 4D supports an efficient oncology workflow and reliable follow-up studies. Completed by syngo TimCT Oncology – the hardware and software solution for seamless whole-body imaging using Continuous Table move – these new applications and workflow tools expand the comprehensive Siemens solution for oncology diagnosis and staging. 1

This application is pending 510(k) review and is not yet commercially available in the U.S.

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News

What is your SPECT’S IQ? Siemens demonstrated industry leadership once again with molecular imaging’s most recent innovation in single photon emission computed tomography (SPECT) – IQ·SPECT1. This new feature in SPECT enables a comprehensive cardiac evaluation including perfusion, attenuation correction, and calcium scoring in as little as five minutes2 when traditional cardiac SPECT perfusion studies can average 15 to 20 minutes. Available for the Symbia® product line, IQ·SPECT allows organspecific cardiac evaluations with enhanced image quality. For medical facilities, this innovation means being able to accommodate more patients in less time and meet a variety of patient needs. IQ·SPECT’s ‘intelligence’ is achieved through a combination of three technologies beginning with SMARTZOOM, a specially designed smart collimator that magnifies the heart while imaging the rest of the torso under traditional conditions. Second, the SMARTZOOM collimator works in a cardio-centric orbit to maximize the amount of cardiac information collected from the patient. Finally, unique IQ·SPECT reconstruction completes the innovation and is seamlessly integrated into the current Symbia workflows and automation features, giving physicians access to the most flexible and versatile system available today. Calcium scoring with SPECT·CT, extracted from a quick lowdose spiral CT, has also become a critical element in the cardiac work-up to evaluate the extent of cardiac disease in patients. Adding the 30-second CT to the SPECT study cannot only illustrate any ischemia present in the patient, but also can assess the buildup of calcium in the coronary arteries. The addition

of IQ·SPECT to these important SPECT·CT studies may lead to new risk stratification algorithms and workups for patients with suspected coronary artery disease. Works in Progress. The information about the product is preliminary. The product is under development and is not commercially available in the U.S., and its future availability cannot be assured. 2 New Product Feature based on preliminary internal data. Actual performance characteristics have not been established. 1

Electronic Health Record for Integrated Care

Klinikum Chemnitz is one of the first hospitals in Germany to link its teleradiology service with an electronic health record (EHR). The EHR makes demographic and administrative data of a telediagnosis available. Provided the patient agrees, images and results from diagnostics can be shared by different facilities. Thanks to a special security system, the data are only accessible to authorized users who

are involved in the patient’s treatment. Siemens equipped the hospital with an overall technology system that includes Soarian® Integrated Care1 (Soarian IC) for information exchange, as well as radiological image communication software. Soarian IC improves the flow of information across institutions and sectors without the need to exchange existing primary systems. As a result, the system supports the cooperation between the individual clinical facilities and simplifies the patient treatment. Together with 14 regional county hospitals as well as medical centers and several practicing physicians, Klinikum Chemnitz sets standards for integrated healthcare in

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Germany. Especially regarding diagnoses in the fields of neurosurgery, traumatology, angiology, and radiology, the hospital supports regional hospitals and practices with its medical expert knowledge. For example, a patient who has been brought into a county hospital after an accident can be scanned with a computed tomography system. The image data is sent electronically to a responsible physician in Klinikum Chemnitz, who then diagnoses the patient and sends back the report. 1

The information about this product is preliminary. The product is under development and is not commercially available in the U.S. or in Canada, and its future availability cannot be assured.

News

Neonatal Care Siemens RAPIDLab® 1245/1265 blood gas analyzers have been enhanced to measure total bilirubin on neonatal whole-blood samples. The RAPIDLab systems determine the neonatal total bilirubin concentration in 60 seconds using multiple wavelength spectrophotometry. Bilirubin is the main bile pigment formed from the degradation of hemoglobin. An increased level of bilirubin in the blood (hyperbilirubinemia) causes jaundice,

the discoloration of body tissues. Neonatal jaundice is usually harmless, a consequence of immature liver function and the breakdown of fetal hemoglobin as it is replaced with adult hemoglobin. Severe neonatal jaundice may indicate a more serious condition, including erythroblastosis fetalis, that is most likely caused by blood incompatibilities between baby and mother. Extremely high levels of bilirubin in infants may cause bilirubin encephalopathy or kernicterus, a form of brain damage.

The Business Partner in MRI “You can’t run a radiology practice without an MRI [magnetic resonance imaging] system,” says Franz Walter, MD. “Demand from referrers and patients for radiation-free imaging is growing steadily.” This is why the radiologist invested in a MAGNETOM® ESSENZA immediately after taking over the recently outsourced radiology practice of the Evangelische Krankenhaus in Zweibrücken, Germany. With a low total cost of ownership, MAGNETOM ESSENZA is ideal for setting up and expanding MRI services. Zhen Jin, MD, agrees. The Director of the MRI Center at Hospital 306 in Beijing, China, looks back on 13 years of MRI service at her institute – and installed two additional systems last year: a 3 Tesla MAGNETOM Trio and a 1.5 Tesla MAGNETOM ESSENZA. The decision for the MAGNETOM ESSENZA was a natural one for both physicians: “It is the first system that is optimized for cost of ownership. Zero helium boil-off and a 50 percent lower electricity consumption compared to conventional systems are just two examples of its affordability,” says Walter. “We wanted a robust system for clinical use to allow more time for research on the MAGNETOM Trio,” Zhen Jin says as she explains the reason for buying two systems within such a short timeframe. MAGNETOM ESSENZA offers full diagnostic capabilities thanks to Tim® (Total imaging matrix). Tim provides flexibility through versatile coil combinations, accuracy through high signal strength and spatial resolution, and speed resulting from parallel imaging. It offers access to the applications needed for both an outpatient practice and a primary care hospital. Zhen Jin also appreciates the integrated IsoCenter Matrix coil of MAGNETOM ESSENZA. Thus, the region of interest is always at the center of the magnetic field, which makes coil repositioning and changing obsolete. With 28 patients a day, she is also happy with the speed of the exams, as is Walter with 22 exams, which include outpatients as well as referrals from within the hospital. Walter mentions a Parkinson’s patient who was referred for an angio exam. First, he was skeptical about being able to achieve diagnostic image quality. Thanks to MAGNETOM ESSENZA’s fast sequences, movement artifacts were reduced and the images were good for diagnosis. “From any perspective, MAGNETOM ESSENZA is definitely up to date,” he says.

At Hospital 306 in Beijing, Dr. Zhen Jin is happy with MAGNETOM ESSENZA’s low cost of ownership.

Dr. Franz Walter of the radiology practice at Evangelische Krankenhaus Zweibrücken likes the system’s ease of use.

www.siemens.com/ESSENZA

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Breast Cancer

Breast cancer is by far the most common cancer among women. The numbers have been increasing worldwide, rising rapidly particularly in younger women.

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Breast Cancer

An Unexpected Encounter Back in the 1980s, a bright young graduate student completed her PhD dissertation on MRI brain diffusion imaging at the Massachusetts Institute of Technology. Little did she know that cutting-edge technology would someday save her life. By Diana Smith

“I was trained as a scientist and have always been interested in health and technology,” says the scientist, who wishes to remain anonymous. “I became very interested in MRI [magnetic resonance imaging] in my first year of graduate school. My doctoral thesis was on MR diffusion imaging, and I continued working on MRI abroad for my post-doctorate research.” A passionate scientist, she continued work in the field and built an impressive global resume. Since 2006, she has been doing research collaboration with a leading hospital in Asia, performing a clinical

research study on breast imaging to compare breast MRI and breast diffusion imaging with conventional techniques such as mammography and ultrasound.

New Imaging Techniques In the blink of an eye, a speck on a mammogram or an aberrant lump felt in the shower can change a woman’s life. Breast cancer is by far the most common cancer among women.1 The numbers have been increasing worldwide, rising 1

http://www.who.int/cancer/detection/breastcancer/en/. Last accessed Nov. 4th, 2008

rapidly, particularly in younger women. According to the American Cancer Society, in 2008, 1.3 million cases will be identified, and almost 500,000 women will die from the disease. In the U.S., breast cancer will be diagnosed in one in eight women. Though rare, men can also get breast cancer. New imaging techniques are helping doctors diagnose tumors with greater precision and less trauma. Mammograms can be less effective in women with dense tissue which makes the images harder to read. Magnetic resonance imaging has been shown to find breast

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lesions underwent diffusion imaging and dynamic contrast-enhanced MRI4 using a 3 Tesla scanner (Siemens MAGNETOM® Trio, A Tim® system). The clinical research study was performed in Asia, where, increasingly younger women are being affected by breast cancer. Younger women tend to have denser (leaner) breast tissue. Dense breast tissue can present special difficulties for disease detection. In mammography, dense breast tissue and tumors both appear white. “It’s like finding a polar bear in a snowstorm,” says the scientist.

Accidental Discovery A chance discovery changed everything, recalls the scientist. “The clinical results from the patient study were really good. Out of curiosity, I went in the scanner for this diffusion technique. No contrast injection was needed with diffusion imaging. It was quick and easy, and I was out of the scanner in five minutes. As I came out, I saw the stricken face of the radiologist and knew something was wrong.” Since the diffusion technique was new and is not yet routine for breast imaging, the radiologist in charge recommended a follow-up with a complete examination and conventional diagnostic methods. These included digital mammography, ultrasound, contrast-enhanced MRI4, and lymph-node mapping.

The scientist’s breast cancer was discovered by chance.

cancers that mammograms miss in a certain group of patients.2 A study published by the Scientific Assembly of the Radiological Society of North America (RSNA) reported that the detection rate for nonpalpable, invasive breast cancers increased by 42 percent in women with dense breasts when mammography was followed by ultrasound.3 “Taking the technology to a new level,” the scientist explains, “diffusion is looking at the water mobility, the movement of water molecules in tissue. We thought this technique would be very sensitive in finding abnormalities in the breast, and it’s perfect when you have a group of patients who have proven biopsies, because then you have histologic comparison. We have the exact pathological specimen to compare with what we see in imaging.” In a clinical study in Hong Kong, 31 female patients with suspected breast

“Women need to know what they should look for in getting the best diagnostic examination.”

Efficacy of MRI and Mammography for Breast-Cancer Screening in Women with a Familial or Genetic Predisposition. N Engl J Med, Vol. 351, No. 5:427-437 3 Mammographic Density and the Risk and Detection of Breast Cancer. N Engl J Med, Vol. 356, No. 5:227-263

Not the Right Destiny At only age 45, the researcher was in a low-risk group with no family history of the disease. Previous mammograms and ultrasounds were normal. A nonsmoker, she was slim and followed a healthy diet. “I was shocked,” she says. “I couldn’t believe it. I always thought I have been healthy and active.” The hours that followed were a roller coaster of emotions, particularly since she was thousands of miles from home and loved ones. “The worst was the moment when you are told you have

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Breast Cancer

“It’s so important to create and offer well-planned radiology departments coupled with women’s health centers to minimize anxiety and suffering after someone is diagnosed with breast cancer.”

cancer,” she explains. “It feels like you just got a death sentence.” That evening, the radiologist in charge, who is also a caring friend, took the scientist to dinner and “turned a potentially sad evening alone after a shocking diagnosis into one that made me think more about friendship, people who care, and the life ahead.”

A Personal Decision Because of her background in medical imaging, the scientist was more informed than most about the diagnostic tools and treatments used in breast cancer. Like American actress Christina Applegate, who elected to have a mastectomy in the summer of 2008 at age 36 to eliminate constant fear and onerous exams every few months, the scientist opted for immediate surgery. “I know of women who had lumpectomies followed by radiation and chemotherapy, and their cancer reoccurred,” she says. “Every woman is different. I made my personal decision to have a mastectomy to have peace of mind and reduce the risks of recurrence to almost zero.”

Recovery “The first couple of weeks were very hard,” remembers the scientist. “I’ve never had any kind of surgery before, and of course, you cannot bathe or even put on clothing yourself. You are very dependent on someone to help you.” She adds, “In a way, I was very lucky that it [finding the cancer] happened where I knew the clinicians. Though I was very far from home when this happened, I was

in a well-known hospital with state-ofthe-art equipment. I found the hospital to be well organized with women’s health and radiology all under the same roof. Everything was very conveniently located in the same building and I could get all the tests done within the first 48 hours.” “I understand many women are less fortunate and they are sent to different places and have to wait weeks before getting all the tests done. The waiting can be bewildering. Some hospitals are still not prepared to offer a streamlined process for people affected with such a diagnosis. Sometimes, the hospital may not have the right imaging equipment or the latest software. It’s easy for a patient to be sent to get multiple tests, get lost in the medical maze, and spend endless hours and days waiting for the results. It’s so important to create and offer wellplanned radiology departments coupled with women’s health centers to minimize anxiety and suffering after someone is diagnosed with breast cancer.”

Speaking Out Today, the scientist is still consulting and she is using her experience to be an advocate and speak to others about the disease and the imaging modalities used to diagnose and treat it. “I’ve learned a lot through this process. I now teach women about early detection and how it helps to save lives. It’s also important to know about the possibilities in detection and treatment,” she emphasizes. “Most people know someone who has had breast cancer. Most people know of

mammography and breast ultrasound. Some know about breast MRI, but they don’t really know enough details, for example, whether their hospital has the state-of-the-art scanner with the latest software or whether it is using a scanner that is ten years old, which does not offer the best resolution or the same functionalities as the newer ones. Women need to know what they should look for in getting the best diagnostic examination and what they should ask their healthcare providers. When patients are wellinformed, they have the best chance for survival and can live a long and healthy life.”

An Enlightened Path “I’m back to my previous activities and actually feel better than before,” says the scientist. “When you go through an experience like this, you get to see who really cares about you and who loves you for who you are. I have a stronger appreciation for people who show kindness despite work pressure and busy schedules. I particularly remember a lateshift nurse and her words of kindness and encouragement when she came to do an IV [infusion] around midnight. When you are flat on your back in a hospital bed, you have time to think, to ponder, and to feel.” She concludes, “I have come from this experience with a greater appreciation for life. I’m grateful for the early detection that helped save my life, and I have certainly grown from the enlightenment and reflections during this unexpected journey.”

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Breast Cancer

A Worldwide Challenge Diverse imaging solutions and advanced, integrated technology are providing a new level of care for breast cancer patients. For a global view, Medical Solutions interviewed three imaging experts around the world:

Gladys Lo, MD, Chief Radiologist, Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital, Hong Kong, China John F. Nelson, MD, Medical Director, Battlefield Imaging, Battlefield Auxiliary Breast Center, Ringgold, Georgia, U.S. Karsten Ridder, MD, Radiological Group Practice, Outpatient Clinic Professor Dr. Uhlenbrock and Partners, Diagnostic Breast Center, St. Josefs-Hospital, Dortmund-Hoerde, Germany 14 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

Breast Cancer

Thank you for finding time to talk to us across many time zones. All of you provide state-of-the-art breast cancer care with integrated imaging systems from Siemens that optimize clinical, operational, and financial workflow. Let’s discuss how diagnosis and treatment of breast cancer has changed since you started in the field. NELSON: I have been practicing for about 20 years, so I’ve seen quite a few

changes. Technologically, we’ve obviously seen huge strides in screening mammography just in the ability to see and pick up lesions. In recent years, most of us in the U.S. and across the world have probably transitioned to digital mammography. I think probably everyone on this panel would agree the improved screenings have saved lives. So, that has really changed the way I practice. Secondly, of course, the different modalities we use to evaluate patients diagnosed with suspected breast cancer also have ballooned. Ultrasound is no longer something that we do occasionally – it’s some-

thing we do all the time. Additionally, advanced techniques like breast MRI [magnetic resonance imaging] have revolutionized what I do as a diagnostician. RIDDER: Changing from analog to digital mammography is like the invention of rubber for the wheel. It is much faster and more precise than before, especially when you are looking at workflow. CAD [computer-aided diagnosis] is a helpful support in managing the workload of a screening center such as ours. But this is only one advantage. On the other hand, digital systems help the radiologist and surgeon communicate with the pathologist. LO: The incidence of breast cancer in Hong Kong has increased to one in 23, and digital mammography is fantastic because Chinese women have very dense breasts. So, advanced digital mammography has really helped to look through the breast tissue, and also in picking up the microcalcifications.

ter for the patients. With our advanced radiology equipment, we get the most sensitivity and specificity we can. Mammography is only one small part of all the basic things that have to be offered along with the other modalities. LO: Our hospital is a private hospital and actually prides itself in getting the best machines. We have a 3 Tesla MRI breast unit, and we’ve been doing a special sequence called diffusion to look at the breast tissue and had some very good preliminary results that will be published in JCAT [Journal of Computer Assisted Tomography] next year and were presented in Toronto at the ISMRM [International Society for Magnetic Resonance in Medicine] this year [2008] in May. You had a special case as a result of the diffusion study. Can you tell us about that? LO: One of my patients is a scientist and is aware of what we are doing. Previously, she had standard mammography, but it was not diagnostic because her breasts were very dense. So, we decided she should have the diffusion examination because it doesn’t involve any ionizing radiation, there’s no injection, and it’s very quick. What happened was that the diffusion study unexpectedly turned out to be abnormal. So, this was followed with a complete contrast-enhanced MRI scan, of course, and at the site where the diffusion abnormality was seen, there was actually a bilobulated rim-enhancing mass with type three signal intensity time graph, quite diagnostic like a BI-RADS [Breast Imaging Reporting and Data System]1 five lesion, and this turned out to be DCIS [ductal carcinoma in situ]. After the MRI was done, I suggested doing an ultrasound as well and we saw the lesion again. I also persuaded her to do mammography again because I was afraid she might have an area of DCIS

How can ultrasound or other modalities improve the ability to detect cancers? LO: Ultrasound has always been popular in Hong Kong because of the very dense breasts the women have here. We’ve always found it to be very useful and complimentary to mammography. MRI, of course, I think is a breakthrough. Like Dr. Ridder, we also have a multidisciplinary approach in our hospital. We communicate very closely with the breast surgeons, pathologists, radiation therapists, and oncologists. Why is it important to be an early adopter of technology? What are the benefits to patients? To the hospital? RIDDER: Here in Dortmund, where we are located, we are a city of 1.5 million. We are part of the hospital’s Radiology Institute, and we have the pressure of the free market. Women are free to decide which institute they want to go to. Having better technology gives us a competitive advantage. The second thing is that with the new techniques, it is bet-

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BI-RADS is a quality assurance tool originally designed for use with mammography. The system is a collborative effort of many health groups but is published and trademarked by the American College of Radiology.

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true for the other two physicians. We’ve actually experimented at our institution with Bruce Porter’s techniques 2, and what we’re doing now is a lot more wholebody MRI for staging and the chest and abdomen for screening, along with our breast MRI. RIDDER: PET·CT is also promising in other cancers, like ovarian cancer or lymphatic cancer. Where we use these PET techniques is also for extended breast cancer and the staging of treatment.

“There are a lot of tools out there that we can parlay into what we are currently doing to add diagnostic capabilities.”

How does an integrated diagnostic strategy affect your patients and your facility’s success? LO: Patients who all of a sudden find out they have some abnormality want to find out the exact extent of the abnormality and what it is right away. If you send them to all different types of places to get it and they have to wait, that’s tremendously stressful on the patient. We are lucky that we have everything in one place, including the hospital. NELSON: In fact, that’s really why our facility was built. We are actually in a breast center, so every modality, including breast MRI, is available. We even offer Saturday morning service. We’re also in a very competitive environment here. We are motivated at our center to place the patient at the center of the wheel and all the spokes go out, but the patient shouldn’t have to move. It’s our job to provide all the services that go along with breast cancer evaluation. RIDDER: I think my colleagues will agree, everyone is short of time, and so the time pressure is extreme. Also, women need to get their results in a short time.

John F. Nelson, MD, Medical Director, Battlefield Imaging, Battlefield Auxiliary Breast Center, Ringgold, GA, USA

that’s only shown with microcalcifications. Both the MRI and the ultrasound may not show a certain percentage of DCIS cases that present with microcalcifications. Indeed, her tumor was at eight o’clock, but on the mammography at ten o’clock, there was a stipulated area that had some microcalcifications in it. NELSON: Was the diagnostic MRI also negative? LO: No, it wasn’t. It was an irregularly marginated mass, but it had a type one graph. So it was indeterminate. It was like a BI-RADS four at the ten o’clock lesion, which was seen on mammography, and a BI-RADS five lesion that was not seen on mammography for the eight o’clock. How are you using other methods of molecular medicine such as PET·CT [positron emission tomography/ computed tomography], SPECT·CT [singe photon emission computed tomography/computed tomography], or biomarkers? NELSON: At our institution, we really reserve PET·CT for women with suspected extensive disease. For most of our women with locally advanced disease, we evaluate with breast MRI, and I bet that is 16 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

Why did you choose women’s health and breast cancer as your field of expertise? RIDDER: Honestly, I think it’s one of the most exciting fields in radiology, with all the new techniques that have been 2

Refer to, e.g., Beatty, J., Porter, B: Contrast-enhanced breast magnetic resonance imaging: the surgical perspective. Am J Surg 193; 5:600-605. Smith J.P., Hanson J., Dawson J., Porter B., Tickman R.J.: emerging technologies in surgical planning for breast cancer. Am J Surg 184; 4:377-9.

Breast Cancer

developed in the last ten, 20 years, and are still being developed. Maybe only comparable to cardiac MRI or multislice computed tomography. NELSON: For me, it was a calling. My sister was diagnosed with breast cancer back when I was still in medical school. She had two kids. I saw how breast cancer affects the patients, their loved ones and families, and changes the course of life for everybody. So when I got to the point of choosing my area of specialization, it was just natural.

“We are lucky that we have everything in one place.” Gladys Lo, MD, Chief Radiologist, Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital, Hong Kong, China

And why did you choose Siemens equipment for your work? NELSON: Battlefield Imaging was a brandnew center built from scratch alongside

“Having better technology gives us a competitive advantage.” Karsten Ridder, MD, Radiological Group Practice, Outpatient Clinic Prof. Dr. Uhlenbrock and Partners, Diagnostic Breast Center, St. Josefs-Hospital, Dortmund-Hoerde, Germany

the rest of our medical facilities about five years ago. We wanted to go completely digital at our center – no film. We weren’t building space for film. I actually flew to Dortmund to look at the digital mammography system they had in place there. We’ve had a long-standing relationship with Siemens, and we have extremely good Siemens service. A lot of what drove my interest in Siemens was that relationship. When I saw the system and compared it with the other two systems available at the time, I just didn’t feel comfortable that either of the others could provide me with the image quality or the back-up service that I knew would be necessary. The same is true for MRI. At that time, the Espree [MAGNETOM® Espree Open Bore MRI system with Tim® technology] was just coming on the market. We have a relatively large patient population; many of our patients are overweight or obese. The Espree just fit perfectly with what we were trying to provide. It was really the first full-field, high-end machine that offered those sort of facilities for the patients. Siemens really had the technology that worked well for us. RIDDER: It’s the whole package you get from Siemens, not limited to just the image quality. For example, we have a

different machine that is supposed to have the same detector as the mammography system from Siemens, but there is no comparison between the two images. I’m also using our MRI for heart examinations and work with other Siemens systems as well. Thanks to the common syngo® user interface, it is easy to switch between the modalities. LO: Prior to getting our Siemens digital mammography unit, we had one from a different vendor. We have images from patients who come for follow-up. The old images are from the other vendor and the new images are Siemens, and it’s like night and day. The new Siemens unit is seeing so much more, and I’m very pleased with that. NELSON: I would add that the Siemens digital unit had several filter combinations, some of which use a considerably lower dose. Compared to our screen film, we were seeing 30 to 40 percent lower doses. We have marketed that very strongly in our community, and it has been very well received. Are you excited about any new trends or innovative leading-edge imaging solutions for the future? RIDDER: We have just started with ultrasound automated breast volume

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Breast Cancer

scanning [ABVS]3. We haven’t used the technology for a very long time, but what I can say now is that we are looking at a very promising technique that holds a huge potential for breast imaging in the future. NELSON: I would echo that there are some other things on the horizon. I think all of us are interested to see if breast tomosynthesis4 is really going to take off. The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S. 4 Caution: Investigational Device. Limited by U.S. Federal Law to investigational use. The information about Digital Breast Tomosynthesis is preliminary. This product is under development and not commercially available in the U.S., and its future availability cannot be assured.

Certainly, we’ve found elasticity imaging in ultrasound very useful. And I’m really excited about diffusion imaging on MRI. There are a lot of tools out there that we can parlay into what we are currently doing to add diagnostic capabilities. Diana Smith is a freelance writer based in Liberty Hill, TX, USA.

3

Further Information www.siemens.com/breastcare www.siemens.com/ news-breastcare

Breast Cancer: Where are we – and where are we heading? Challenge: “It was easy, and I was out of the scanner in five minutes,” says the scientist. “As I came out, I saw the stricken face of the radiologist and knew something was wrong.” Working on MRI diffusion, a promising breakthrough imaging technique for the breast, a scientist unexpectedly discovers her own disease. One chance test completely changed her life, but that was just the beginning of an arduous emotional and physical journey. Solution: Today, physicians and clinicians are using an arsenal of integrated diagnostics that have revolutionized the management of breast cancer. “I think probably everyone would agree that improved screenings have saved lives,” says John F. Nelson, MD, Medical Director of Battlefield Auxiliary Breast Center in Ringgold, Georgia, U.S. “That has really changed the way I practice.” Integrated diagnostics have other benefits, including improved workflow and patient convenience. Gladys Lo, MD, Chief Radiologist at Hong Kong Sanatorium, emphasizes how new approaches to diagnosis and treatment have positive emotional ramifications. “For patients who all of the sudden find out they have some abnormality, they would like to find out the exact extent of what it is right away. If you send them to all different types of places and they have to wait, that’s tremendously stressful on them.” Result: Technologically, huge strides have been made in the imaging field in the last two decades. Integrating laboratory diagnostics, advanced imaging, and information technologies can improve a patient’s outcome at every stage of care. In addition, integrated technology affects workflow. “It is much faster and more precise than before,” says Dr. Karsten Ridder of St. Josefs-Hospital, Dortmund, Germany. The journey of detecting, coping with, and beating breast cancer resulted in an enlightened new perspective for the scientist. Now, this survivor gives real advice, not only on early detection and treatment, but also because of her background, specifically on what to look for in hospital imaging equipment and how the level of technology may make a difference in a person’s life. All scanners are not created equally. 18 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

The ACUSON S2000 ABVS Automated Breast Volume Scanner reduces operator dependence and variability.

Patient with a 2.8-centimeter, grade 3, invasive ductal carcinoma in the right breast imaged with digital mammography (left) and breast tomosynthesis. The mediolateral oblique (MLO) digital mammography view shows dense breast tissue with subtle distortion in the lower breast. The MLO tomosynthesis slice shows a spiculated mass in the lower breast.

MAGNETOM Espree – Pink is a dedicated MR Breast Scanner with a 70-centimeter Open Bore at 1.5T and an ultra-short 125-centimeter system length.

Diverse Imaging Solutions In a multipronged, comprehensive approach, Siemens combines laboratory diagnostics, advanced imaging, and information technologies to help physicians detect, diagnose, and treat breast cancer earlier, faster, and with greater precision. New technology offers a range of breast care solutions – all designed to contribute to successful disease management.

diagnosis of the breast. ACUSON S2000 ABVS features an integrated room suite design that combines the advanced ACUSON S2000 ultrasound system and a column stand with an arm assembly, which holds a transducer pod specially designed for automated ultrasound breast imaging. It supports a high patient load with 250 to 400 single images acquired in one scan to calculate the volumes, which are sent to a dedicated ABVS Workplace for analysis and manipulation. The system features the anatomical coronal plane, which is not available using conventional ultrasound and includes semiautomated reporting features and comprehensive BI-RADS report capabilities.

MAGNETOM Espree – Pink Siemens announced the latest innovation in breast MRI, MAGNETOM® Espree – Pink, the new dedicated MRI Breast Scanner with a 70-centimeter Open Bore at 1.5 Tesla and an ultrashort 125-centimeter system length. Both the 70-centimeter Open Bore scanner and the new breast coil (Sentinelle Vanguard for Siemens) offer an enhanced level of patient comfort, especially for obese and claustrophobic patients. The system has the capability to position the patient feet-first or head-first and provides excellent access to perform biopsies. Sentinelle Vanguard for Siemens offers excellent image quality and optimized biopsy access for higher accuracy in intervention and faster examination time. The dedicated workplace includes syngo® BreVis1 for flexible reading and reporting and syngo BreVis Biopsy1 for fast and accurate MR breast biopsy workflow with automatic calculation of target coordinates.

ACUSON S2000 ABVS Automated Breast Volume Scanner

Breast Tomosynthesis The latest technology now under development in full-field mammography, breast tomosynthesis 3, is a 3D imaging technology that acquires 2D projection images of a compressed breast at multiple angles during a sweep of the X-ray tube. Poised to enhance mammography, the new technology will take the two-dimensional images and reconstruct them to reveal depth – the third dimension of anatomy. Tomosynthesis slices have the potential to show tumors that remain invisible in individual images. This information about this product is preliminary. The product is under development and not commercially available in the U.S., and its future availability cannot be ensured. The information about this product is being provided for planning purposes. The product is pending 510(k) review and is not yet commercially available in the U.S. 3 Caution: Investigational Device. Limited by U.S. Federal Law to investigational use. The information about Digital Breast Tomosynthesis is preliminary. This product is under development and not commercially available in the U.S., and its future availability cannot be assured. 1

2

The ACUSON S2000™ ABVS Automated Breast Volume Scanner 2 streamlines workflow and reduces operator dependence and variability by quickly and comfortably surveying and acquiring full-field sonographic volumes for comprehensive review and

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“National Jewish Health and Siemens share a common vision of bringing laboratory diagnostics together with imaging in order to give our patients the best care possible.” Michael Salem, MD, President and CEO, National Jewish Health, Denver, CO, USA

Bringing Personalized Medicine into Focus For 109 years, National Jewish Health has sought to offer patients the best possible care. U.S. News & World Report has ranked National Jewish Health the number one respiratory hospital in the nation for 11 years straight. It is continuing its legacy by launching a personalized medicine initiative, seeking to become a nationally recognized clinical thought leader among American healthcare providers. By Amy K. Erickson

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“Siemens Financial representatives were very responsive to our questions. They took the time to understand National Jewish Health and our financing needs.” Christine Forkner, CFO, National Jewish Health, Denver, CO, USA

In collaboration with Siemens, National Jewish Health’s individualized medicine strategy is aimed at merging research and clinical efforts to improve and develop novel imaging and laboratory diagnostic technologies. Medical Solutions sat down with Michael Salem, MD, President and Chief Executive Officer of National Jewish Health, and Christine Forkner, Chief Financial Officer at National Jewish Health, to discuss their strategic alliance with Siemens, their shared vision for collaborative research, improved diagnostic imaging, and financing. It is an ambitious endeavor: National Jewish Health will integrate Siemens technology throughout the facility’s 19-acre campus in Denver, Colorado, U.S. – in order to offer patients advanced diagnoses and treatments.

Personalized medicine is a new therapeutic approach that uses genetic and other information about a person to tailor the prevention, detection, treatment, and monitoring of disease. How does partnering with Siemens Healthcare bolster your strategic plan to advance the field of personalized medicine and use those advances to better care for your patients? SALEM: Personalized and preventive medicine is about the right diagnosis and treatment for the individual patient. By combining our strengths in technology, patient care, and research, Siemens and National Jewish will advance the idea of early detection and prevention. We will be able to provide more accurate diagnoses that lead to more targeted and effective therapies for our patients and

patients around the world. To do this, we set up three pillars of infrastructure: the Integrated Bioinformation and Specimen Center, the Center for Genetics and Therapeutics, and the Institute for Advanced Biomedical Imaging1. Why did National Jewish Health select Siemens Healthcare as a clinical and Siemens Financial Services, Inc. [Siemens Financial] as a financial partner? SALEM: Siemens is a world-class company and our collaboration brings together the best of the best in terms of faculty, staff, and technology. We share a common vision of bringing laboratory diagnostics together with imaging in order to 1

The Institute for Advanced Biomedical Imaging is a registered trademark of National Jewish Health.

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Patient-centered Medicine

give our patients the best care possible. FORKNER: From a financial standpoint, when we looked at Siemens Financial, we were looking for a broad agreement with a broad scope and a wide range of criteria. We considered how easy they are to work with, their clear and straightforward documents, their experience in dealing with local authorities, and their expertise in tax-exempt lending. We compared their offers with several national and large regional banks, equipmentlending companies, and their competition. Siemens Financial came out on top. How will National Jewish Health and Siemens Healthcare benefit from this joint effort?

Summary Challenge: • Moving away from a reactive trialand-error method of practicing medicine to a predictive, personalized model • Practically implementing better diagnostics that lead to more effective treatments • Obtaining financial assistance to fund state-of-the-art technologies Solution: • Collaborating with healthcare institutions to improve and develop novel imaging and diagnostic technologies • Integrating Siemens technologies throughout National Jewish Health to help diagnose respiratory, cardiac, and rheumatologic diseases • Merging the institution’s research and clinical efforts at the point of care for the benefit of the patient • Providing easy, affordable financing options to healthcare entities Result: • Improved patient care • Development of a practical model of proactive personalized healthcare • Advancement of molecular medicine • Better diagnostic and imaging technologies

SALEM: We think National Jewish is very well positioned to help Siemens advance its technologies. In our laboratories, we have invented and are committed to a number of novel diagnostic tests – whether they are genetic tests, biomarkers, or new predictive tests that can track patient progress – and we think a partnership with a leader like Siemens will allow us to bring these things to patients a lot sooner than we otherwise would have. Additionally, we have tremendous expertise and access to samples and patients. With technology from Siemens and great minds on both sides, we have the opportunity to be very successful. Why did you choose Siemens Financial to finance the equipment and technology? In other words, what differentiates Siemens from other lending sources? SALEM: This is a competitive business and we were looking for a business partner and a research partner. FORKNER: We went with Siemens Financial because our market analysis indicated that they had the best rate and some of

the easiest processes. Siemens Financial representatives were very responsive to our questions. They took the time to understand National Jewish Health and our financing needs. They had excellent forms, which minimized lawyer time and expense. Overall, among the companies we considered, Siemens Financial came in as the number one frontrunner from a financial standpoint and in the broader relationship. On top of that, they were nice people to work with, which is important, especially in the most complicated financial transactions. I think we came together to make an excellent deal. How important is it that Siemens Financial provide equipment financing options to healthcare providers? FORKNER: It’s imperative that they do so for several reasons. Healthcare financing is always complicated. A lot of hospitals are experiencing a credit crunch at a time when radiology equipment continues to advance. You have to be very competitive in today’s healthcare world. It is beneficial to everyone that Siemens Financial not only has the financing, but also the expertise to make a lot of different financ-

Siemens Provides Personalized Financing Options Siemens Financial Services, Inc. provides innovative financial solutions to healthcare providers such as National Jewish Health. With expertise in asset-based lending, capital markets, equipment financing, commercial trade finance, and vendor financing, each transaction is tailored to fit the specific borrowing needs of the client. The financing arm for healthcare at Siemens Financial Services has been in existence for over 20 years. “We offer a turnkey approach,” says Lynn Beckham, Vice President of Tax-Exempt Healthcare Corporate Finance for Siemens Financial Services. “The customer not only looks to us for equipment, but also for financial assistance, as was the case with National Jewish Health.” After Siemens identified the best funding avenues for National Jewish Health, the US$13 million transaction was completed in about five weeks from start to finish. “We offer excellent customer service,” says Beckham. “Our rates are very attractive and we are always accessible. With this equipment, National Jewish Health will be able to expand and do more research, which in the end, means helping more people.”

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ing options available – from tax-exempt to not tax-exempt, from an operating lease to a capital lease, there are a lot of options out there. Siemens Financial not only makes those available, they also make them easy. How are current U.S. market conditions affecting your ability to fund projects? FORKNER: The market has impacted budgets across the country and ours is no exception. Siemens Financial worked wonderfully with us to help get our program financed. National Jewish has a dedicated donor base and, with relationships with industry leaders like Siemens, I think National Jewish will weather this crunch just fine. National Jewish Health’s mission of personalized medicine is aligned with Siemens strategy of providing cuttingedge technology to improve patient care. Can you highlight a few examples of how this collaborative effort benefits patients? SALEM: I think the benefit to patients will be this transition to more preventive care – this notion or idea of early detec-

Collaboration Strengthens Patient Care A cornerstone of National Jewish Health’s mission to advance personalized medicine is the integration of Siemens technology within the existing medical infrastructure. Currently, physicians and clinicians at National Jewish Health are supported by a wide range of Siemens in vivo diagnostics and information technology, including SOMATOM® Definition, SOMATOM Sensation 64, MAGNETOM® Avanto, syngo® Imaging and syngo Workflow, BiographTM 40, ARCADISTM Avantic, and c.cam. Additionally, National Jewish Health plans to install several Siemens solutions for in vitro diagnostics in the near future. The Institute for Advanced Biomedical Imaging, which opened its doors in the spring of 2008, houses two Siemens computed tomography (CT) systems and one Siemens PET·CT (positron emission tomography-CT) system. The institute also has an integrated radiology information system (RIS) and picture archiving and communication system (PACS) that uses the same syngo architecture as the imaging modalities, leading to streamlined data

reconciliation and consistency. Additionally, National Jewish Health and Siemens are launching several collaborative research projects that seek to improve the diagnostic capabilities of several imaging technologies. The overarching goal of these projects is to detect disease earlier and make more precise diagnoses, leading to improved patient care. These projects include: • Using technology from Siemens to develop techniques for detecting very small lung nodules (four to eight millimeters in diameter) in individuals at a high risk for lung cancer • Developing a model of the lung that can be used by others to calibrate CT systems in order to produce comparable images • Developing a Quantitative Imaging Laboratory at National Jewish to improve quantitative imaging techniques for better integration of radiologic and molecular imaging

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Patient-centered Medicine

tion. How do you practically implement the idea of prescribing medications more precisely? Patients suffering from COPD [Chronic Obstructive Pulmonary Disease] offer one example. COPD is really a syndrome, a broad group of conditions grouped together through a fairly crude diagnostic tool – the amount of air a person can exhale in one second. Advanced imaging is increasingly able to distinguish the two main characteristics of COPD – lung destruction and airway inflammation. As we learn to distinguish the varieties of COPD and couple that with information gleaned from biomark-

ers and genetics, physicians will have improved knowledge about a patient’s disease. Physicians will be able to target treatments to address specific situations within the COPD spectrum, and patients will have better outcomes. We also expect to improve imaging of the right side of the heart, which is less advanced than imaging of the left side of the heart. It can often be difficult to determine whether a patient’s shortness of breath – a common complaint among our patients – is caused by problems in the lung or in the right side of the heart, which pumps blood to the lungs. By

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developing improved tools to measure right-heart function, we will better understand our patients’ needs and address them more effectively. One of our collaborative research projects also seeks to detect potentially cancerous lung nodules when they are smaller than we can currently detect. Earlier detection and removal of cancerous nodules could significantly improve survival in lung cancer. What are the measurable outcomes of the partnership between National Jewish Health and Siemens?

Patient-centered Medicine

SALEM: Research results and patient outcomes. As our collaboration produces new methods and tools for diagnostic imaging and healthcare solutions by bringing together imaging and the clinical reference labs, we will share that knowledge, which may change the way medicine is practiced. And, as the broader diagnostic imaging and laboratory communities adopt those new methods and tools, patient outcomes will improve. Providing testing using cutting-edge diagnostics and targeted therapies is a real challenge. We think if we put together the best of what the industry

has to offer and the best of what academia and medicine have to offer in this environment here at National Jewish Health, then we have the potential to really help patients. Amy K. Erickson is a Chicago-based writer specializing in medicine, science, and biotechnology.

Further Information www.siemens.com/ personalized-medicine

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Magnetic Resonance Imaging

Expects to improve diagnosis for nervous and circulatory systems: Dr. Romeu Côrtes Domingues

Room to Breathe Siemens 70-centimeter Open Bore technology makes magnetic resonance imaging less claustrophobic and more comfortable, enabling faster and better imaging for delicate cases. By Reinaldo José Lopes

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Magnetic Resonance Imaging

It’s been a long wait. In October 2007, Romeu Côrtes Domingues, MD, and his colleagues at CDPI (Clínica de Diagnóstico por Imagem, a major imaging diagnosis facility in Rio de Janeiro, Brazil) visited a factory in Erlangen, Germany, and were able to have a ’sneak peek‘ view of MAGNETOM® Verio, Siemens new 3 Tesla (3T) Open Bore magnetic resonance imaging (MRI) device. “It was still a top secret project back then,” recalls Domingues. “We had almost closed a deal with another manufacturer, but when we saw MAGNETOM Verio, we realized that this was a completely different game – it was surely going to become the new benchmark in the market. We simply had to buy it – and that’s what we did last year.” Since it was a novel technology, though, MAGNETOM Verio still had to wait in order to be registered and approved by Anvisa (Agência Nacional de Vigilância Sanitária), the Brazilian counterpart to the FDA. “They took almost six months to do it, but thank goodness the device is finally about to be installed,” says Domingues with palpable relief. The team at CDPI now expects to employ MAGNETOM Verio to reduce rejection by claustrophobic patients and significantly improve the diagnosis of a variety of conditions, especially those involving the nervous and circulatory systems. “We are happy and very proud to be the first in Brazil, and among the first in the world, to have this kind of technology at our disposal. Because we focus so much on MRI – we have 50 doctors working on it, with thousands of exams per month – we need the best. And there’s no question MAGNETOM Verio is the best option.” The Brazilian radiologist and his colleagues have been familiar with Siemens MAGNETOM systems for quite a while and have been working with a MAGNETOM Symphony and a MAGNETOM Avanto. “Siemens became the world leader in the market share of MRI devices, thanks also to their MAGNETOM Espree’s Open Bore concept,” states Domingues. “Still, mag-

“There’s no question MAGNETOM Verio is the best option.” Romeu Côrtes Domingues, MD, Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil

netic resonance can be a difficult method when you take into account the patients’ rejection rate due to claustrophobia or lack of comfort. Conventional small bores may frighten off about three percent of patients – sometimes we even need to hold a patient’s hand to calm him or her down while the session proceeds,” he says.

Ten Centimeters that Matter Open Bore MRI changes that by providing ten centimeters of additional breathing room for the patients. “It may not seem so at first, but ten centimeters matter a lot. You’ll never want to be examined in a standard-bore device after that,” says Domingues. Combined with the Open Bore approach, MAGNETOM Verio will allow the team at CDPI to handle difficult procedures in a much more flexible way and, thanks to 3T, to provide them with a welcome enhancement in resolution and precision, and also with a bigger chance of an early diagnosis in a number of conditions. “Of course, we’re talking about doubling the magnetic field. And that means doubling the signal-to-noise ratio, too. Some lesions that are nearly invisible for a 1.5T machine – in a patient with a case of epilepsy that’s difficult to control, for instance, or breast cancer at the earliest stages – are sure to show up with 3T.” But at least in most systems, the precision of 3T comes at the price of “unfriendly 60-centimeter bore systems,” as Domingues puts it – precisely the ones that look the most oppressive to patients. “The unique combination of 3T with Open Bore in MAGNETOM Verio will help us enjoy the best of both worlds,” he says.

Domingues explains that both claustrophobic patients and children, who normally have a hard time undergoing MRI, stand to benefit from Open Bore technology. “Depending on the kind of procedure, you can actually let the mother caress the child during the exam. Obese patients, up to 250 kilograms, can also be redirected to it. And there are positioning advantages for those with chronic pain or limited mobility.” Even for patients who do not suffer from any disability and feel just fine in a tight place, Open Bore technology can make a difference, according to the Brazilian radiologist. “Let’s say you need to image a patient’s wrist. In any conventional machine he would have to go in with his wrist first, and we all know how unbearable it is to keep your arm stretched for 15 minutes. If you need to examine someone’s knees, lumbar vertebrae or abdomen, the patient’s head can stay outside the tunnel, as we say. And that’s a lot less stressful.”

Total Imaging According to Domingues, another important factor for the success of Siemens MRI systems is Tim® (Total imaging matrix) technology. “This is crucial, because MRI procedures have now become so common that between 20 and 30 percent of our patients arrive here with requests to image two or three different areas,” he says. With Tim, up to ten coils can be used at the same time. That means there is no need for the patient to get in and out of the system, or to change position inside it. At the end of a typical working day of 15 hours, the result is that about two or three extra patients

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Open Bore systems open up new possibilities: MAGNETOM Espree and MAGNETOM Verio facilitate exams of claustrophobic, obese, and immobile patients, or patients in pain.

Summary Challenge: • Patients’ rejection to MRI due to claustrophobia • Difficult or impossible imaging of obese patients, patients that are immobilized, or people with chronic pain • Lack of Open Bore MRI systems with a 3T magnetic field Solution: • Investment in MAGNETOM Espree, a 1.5T, 70-centimeter Open Bore system, and its newly released 3T counterpart, MAGNETOM Verio Result: • Improvement in workflow – up to 60 MRI examinations in a single day • More comfort for patients • Increased precision in difficult exams • Better research capabilities

have been examined. “We broke our own record a couple of months ago, doing 60 sessions in a single day. One would never be able to reach the same amount with a different machine,” reports Domingues. With MAGNETOM Verio, the team at CDPI hopes to strike a rewarding balance between faster imaging and higher resolution. “By doubling the magnetic field, going from 1.5T to 3T, you could in theory, image a brain tumor in ten minutes, instead of spending 20 minutes on it. But with 3T, in those cases, we can produce a complete study of the relevant brain area, including perfusion, spectroscopy, and functional data, that enables us to classify the tumor as malignant or benign with a very high degree of certainty. That would take about 15 minutes, but the gain in diagnostic quality would more than compensate for the additional time we spend,” he says. Besides, the combination of Tim, 3T, and Open Bore technology is also suited to dramatically improve the diagnosis of numerous conditions, explains Domingues. In the case of breast tumors, MRI can both bring to light nodules that are

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hard to detect through mammography, and guide doctors to obtain biopsies of the affected tissue with a high degree of precision. He says: “You are able to obtain ‘slices’ of breast tissue that are 0.5 millimeters thin, so absolutely nothing eludes us.” Thanks to Tim, an interesting trend in recent times is the use of MRI to image a patient’s body from head to toe. “It can be very useful to detect metastasis. In patients with diabetes, where there’s systemic damage to blood vessels, you can inject the contrast in the whole body in order to have a global picture. The same goes for myositis, a condition that affects the whole musculoskeletal system,” Domingues says. “In angiographies with 3T, you’re able to do dynamic studies where the contrast is literally seen arriving at the artery and coming back through a vein real fast.” The same praise goes to neurological exams. According to Domingues, smaller and more precocious lesions tend to appear in better detail and, with the help of spectroscopy, it is easier to say whether a given abnormality is a tumor, an inflammatory lesion, or a stroke. And

Magnetic Resonance Imaging

“Once a patient is examined with MAGNETOM Verio, he won’t think of being imaged in another machine.” Romeu Côrtes Domingues, MD, Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil

there is also the possibility of dynamic imaging – a knee in movement, for example, a kind of exam that is often sought by Brazil’s top soccer players.

Research Apart from the benefits for patients, Domingues sees MAGNETOM Verio as a boost for CDPI’s research capabilities. “We’ve been able to forge a strong partnership with universities in Brazil and abroad. It’s also a strong motivating factor for our doctors. It’s always good for them to get away from cases of headaches and meniscus lesions every now and then.” The research output has been so great, says Domingues, that his group has had 21 papers accepted for presentation at the 2008 annual meeting of the Radiological Society of North America

(RSNA) – more than all the Brazilian research groups put together in previous meetings. A paper by Domingues and his colleagues that has just been accepted for publication in the American Journal of Roentgenology shows how positron emission tomography (PET) and MRI can be combined to get a clearer picture of lesions in the nervous system, abdomen, and bones when the data from PET·CT (computed tomography) is somewhat doubtful. Domingues hopes that MAGNETOM Verio will keep his team at the top of their game and, more importantly, the patients will feel like it is the best solution for them. “I believe that, once a patient is examined with MAGNETOM Verio, he won’t think of being imaged in another machine. The difference between it

and any other device is just staggering. That’s why we’re sure that this is an investment that will pay off. If you do the math, you’ll find out that, at the end of five years of work, you can buy another machine thanks to the time you saved with the first one,” he concludes. Reinaldo José Lopes is a science and health writer at G1, Brazil’s largest news website.

Further Information www.siemens.com/Verio www.siemens.com/Espree

Dynamic Duo In the U.S., MAGNETOM Espree and MAGNETOM Verio also help to image children, claustrophobic and obese patients, and body areas that are difficult to image. The medical team at South Jersey Radiology Associates, New Jersey, like its colleagues in Rio de Janeiro, are witness to the flexibility and precision of both systems. “They enable us to capture patients we would not have been able to image with conventional MRI,” says William F. Muhr, MD, Director of Body Imaging at the private practice. In two of their locations east of Philadelphia, they decided to replace conventional 1.5 Tesla systems with the Siemens Open Bore technology. Muhr says MAGNETOM Espree and MAGNETOM Verio help to improve workflow at their facilities by easing the posi-

tioning of patients and diminishing the number of image retakes caused by anxiety-related movements. Thanks to MAGNETOM Verio’s 3 Tesla field, the New Jersey team also obtains high-quality images of difficult body areas. “We get really good image quality in abdominal exams for obese patients, and also in challenging exams of small structures like the wrist,” Muhr remarks. For orthopedic exams, MAGNETOM Verio is fast, around 15 minutes on average, compared to 30 minutes in conventional systems, and that is probably a factor in the high acceptance rate among patients: For their next exam, around 90 percent of patients ask to be imaged on MAGNETOM Verio again.

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Designed for Adaptive Radiation Therapy, the ARTISTE solution enables radiation oncologists to create treatment plans that include IGRT, conformal radiation therapy, IMRT, high-precision radiation therapy, and gated treatments.

Radiation Therapy

The Future of Oncology: The ARTISTE Solution At Baton Rouge General Medical Center’s Pennington Cancer Center in Louisiana, U.S., the staff shares the belief that cutting-edge cancer care should not be limited to patients at larger hospitals and academic medical centers. By Sameh Fahmy, MS

Pennington Cancer Center partnered with Siemens to rapidly and efficiently deliver advanced and routine radiation therapy close to home, providing a wider range of options for a larger scope of patients than ever before. “We need to provide state-of-the-art cancer care for the people of this state so that they don’t need to go elsewhere,” says Director of Radiation Oncology Zack Smith, RT, MBA. “They should stay here – where their families are, where their community is, where their jobs are, and where they have all of the support mechanisms that will make their treatment easier.” To that end, the 544-bed, communityowned hospital became the first in the United States to install the Siemens ARTISTE™ integrated radiation therapy solution. By combining a range of advanced imaging options, rapid image acquisition and processing, and precise treatment delivery, the system has given the Pennington Cancer Center the flexibility to treat routine cases as well as those that require complicated treatment

plans, such as Intensity-Modulated Radiation Therapy (IMRT), while maintaining a quick and efficient workflow.

Enhanced Flexibility Pennington Cancer Center installed ARTISTE in February of 2008. Medical Director William Russell, MD, explains that its flexibility was a key factor in their decision. The solution gives Russell and his colleagues the ability to create treatment plans that include Image-Guided Radiation Therapy (IGRT), conformal radiation therapy, IMRT, high-precision radiation therapy, and also gated treatments. “We chose ARTISTE because it gives us the full spectrum of treatment options,” Russell says. “It allows us to efficiently and rapidly deliver routine radiation therapy for patients who don’t require overly sophisticated plans, while also enabling us to deliver more complex treatments using the same platform.” ARTISTE is engineered specifically for Adaptive Radiation Therapy (ART), which aims to precisely deliver dose to the target while sparing surrounding healthy tissue.

Russell points out this is particularly important because the size and shape of tumors change during treatment and because tumors can shift in response to factors such as weight loss, inflammation in nearby tissues, and normal physiological functions – for example, lung tumors move as the patient breathes, and the prostate shifts in response to fullness in the bladder and rectum. To help ensure that the treatment dose is delivered to the target and not healthy tissue, this radiation therapy solution allows physicians to image the patient just prior to treatment, verify that the patient position is correct, and adapt to any anatomical changes immediately before – or in some cases during – treatment. ARTISTE also offers the ability to incorporate the dose used for pretreatment imaging into the treatment plan so that clinicians can accurately monitor the dose delivered to the patient. “Siemens has always been a leader in healthcare solutions, so for us, it made the most sense to stay with a company that had a proven track record in both therapy

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and imaging for a combined modality machine,” Russell says. “This system is the future of radiation oncology.” The ability to choose between multiple imaging options is one of the features that makes ARTISTE so unique. Russell explains that for patients with simple treatment plans, ARTISTE offers twodimensional OPTIVUE™ portal imaging for low-dose, high-resolution image quality. In situations where additional imaging information is required, it offers its powerful and unique 3D MVision™ Megavoltage Cone Beam Imaging. MVision uses the treatment beam to provide 3D target imaging with excellent soft-tissue resolution. MVision also allows clinicians to incorporate dose distributions from cone beam imaging into patient treatment plans.

Rapid Workflow, Improved Outcomes The images ARTISTE produces are of exceptionally high quality, while maintaining acquisition speed. “The speed with which the megavoltage cone beam image is acquired and the speed at which the software arrives at a solution for adaptive targeting is three minutes,” Russell explains, “and that’s very fast.” The system’s rapid speed increases patient comfort by decreasing their time on the treatment table and, Russell says, can improve outcomes by minimizing the likelihood that the patient or the

target will shift while images are being acquired. Smith notes that another benefit of MVision is that it is fully integrated and therefore requires no addon hardware. “When you bolt on accessories, you introduce the possibility of set-up errors and need extra quality assurance steps,” Smith says. “Because everything is in line with MVision, what you’re seeing is a Beam’s-Eye-View [BEV].” ARTISTE’s In-Line™ Technology also streamlines workflow and increases patient comfort. Therapists are afforded clear access to the patient during setup, and the risk of collision between the linear accelerator and objects in the room, such as a patient’s wheelchair, is minimized. “But the biggest plus for me is that when patients walk into the room, they see a sleek system that is not going to enclose them with a bunch of imaging apparatus coming out of the sides,” Smith says. “It’s a very unthreatening environment, and that makes the patients very relaxed and allows us to take care of them quickly.” ARTISTE includes the 160™ MLC Multileaf Collimator to provide highly accurate and precise field shaping. Its leaves move at four centimeters per second to quickly deliver treatment, and its low transmission and leakage minimizes dose to healthy tissue. It has a small, fivemillimeter leaf thickness over the full field to improve conformity to the tumor shape.

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Smith says most patients will only need a fraction of ARTISTE’s capabilities, but for some patients, even a small increase in precision can result in significantly improved outcomes. He recalls one patient who was treated for a spinal metastasis in her upper thorax but suffered a recurrence several months later. The cancer came back in the same region and had started to deteriorate a vertebral body, causing pain. The spinal column had already received a near-maximum radiation dose, Smith says, and without the new technology, the sole treatment option would have been analgesics and a treatment that would only have slowed the progression temporarily. Using MVision cone beam guidance, ARTISTE allowed the patient’s physician to pursue a more aggressive treatment plan with a degree of precision that Smith describes as “almost like a surgeon’s knife.” He adds, “By the third treatment she was pain free, and today she’s still pain free. So her outcome was better. The physician having that ability to make a difference in this patient’s outcome just because of ARTISTE tells me that it’s the right technology.” Another feature that increases treatment options for patients is its 550 TxT™ Treatment Table, which accommodates patients of up to 550 pounds (250 kilograms). Russell says the combination of ARTISTE and Siemens SOMATOM® Sensation Open large-bore computed

Radiation Therapy

ARTISTE’s treatment table, we can offer high-quality, precise treatments to our larger patients.” Large patients, as well as patients with tumors located off-isocenter, also benefit from MVision’s extended field-of-view (FOV) option.

“ARTISTE is cutting edge now and it’ll still be cutting edge next year, the year after that, and for years to come.”

Ease of Operation, Financial Rewards

Zack Smith, RT, MBA, Director of Radiation Oncology, Pennington Cancer Center, Baton Rouge General Medical Center, Baton Rouge, LA, USA

tomography (CT) system, which Pennington Cancer Center uses for planning, gives them the ability to effectively treat obese patients, using the same table for both imaging and treatment – helping avoid shifts in patient positioning.

Patient setup, imaging, verification, and treatment delivery are controlled via Siemens intuitive syngo® RT Therapist workspace. Adaptive Targeting™ on the software quickly and reliably registers pretreatment images with the planning CT. syngo RT Therapist is a component of syngo Suite for Oncology1, a streamlined, scalable workspace solution that provides members of the clinical team with the tools and data they need to efficiently accomplish their tasks. syngo Suite for Oncology also includes syngo RT Oncologist, syngo RT Physicist, and syngo RT Dosimetrist. Smith says that using syngo software across the Cancer Center creates efficiency by giving clinicians a common operating platform from which to work. “So even if I don’t operate the CT very often, I can go to it and the browsers are the same and the buttons are familiar and intuitive,” he says. Smith says the syngo platform makes it easier for new users to operate ARTISTE and has simplified its integration into the Cancer Center’s entirely paperless environment. As a Siemens partner and the first ARTISTE site in the United States, Pennington Cancer Center hosts clinicians from across the nation and shares its expertise with centers that are adopting the solution. Russell and Smith say that as a community-owned hospital, Baton Rouge General has a duty to be a good financial steward. The addition of ARTISTE accomplishes this goal, they say, by providing measurable financial benefits. Smith says its rapid

“It used to be that when patients weighed over 300 pounds [136 kilograms], not only could we not treat them well, but we couldn’t plan the treatment well,” he explains. “Now, with the combination of Siemens wide-bore CT scanner and

Treating Challenging Cases in Europe In Europe, MAASTRO Clinic in the Netherlands and the German Cancer Research Center (DKFZ) in Heidelberg were the first to install ARTISTE. Clinicians at both centers say its flexibility has allowed them to confidently treat a number of challenging cases. ARTISTE was used at DKFZ, for example, to treat an inoperable esophagus tumor. “Treatment for this type of tumor demands a very complicated radiotherapy approach,” says Professor Peter Huber, MD, Head of the Radiation Oncology Clinical Cooperation Unit at DKFZ. “Using the ARTISTE 160 MLC Multileaf Collimator, we were able to significantly improve the precision of the dose delivery while protecting immediate surrounding healthy tissue.” MAASTRO Clinic has treated challenging clinical cases such as a metastasized tumor in the abdominal region and a patient with two separate metastases: one in the head and neck region, and one in the knee cap. “ARTISTE’s imaging flexibility and simplified workflow help us to confidently treat proliferated tumors in a wide range of areas of the body,” says Bas Nijsten, MSc, Medical Physicist in the Maastricht Radiation Oncology Department. “The advanced, high-end imaging capabilities of ARTISTE allow us to fully integrate all our Image-Guided Radiation Therapy and MAASTRO-developed Dose-Guided Radiation Therapy methods in one clinical workflow.”

1

The COHERENCE Suite of Oncology workspaces is currently being rebranded to syngo Suite for Oncology. The mentioned workspaces are available for purchase under the COHERENCE brand name.

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Radiation Therapy

Summary Challenge: • Maintaining rapid workflow while delivering increasingly complex radiation therapy treatments • Achieving high image quality in challenging situations • Treating irregular tumors and tumors near critical structures • Effectively imaging and treating obese patients Solution: • Expanded treatment options with the ARTISTE integrated imaging and radiation therapy solution • Rapid image acquisition and Adaptive Targeting help ensure that treatment begins within three minutes after positioning • MVision Megavoltage Cone Beam Imaging delivers exceptional 3D soft-tissue resolution with extended field of view • In-room CTVision allows direct comparison of daily patient anatomy with planning data • Fine-leaf resolution of 160 MLC allows exceptional large-field conformity and minimal dose to organs at risk • 550TxT Treatment Table accommodates patients up to 550 pounds (250 kilograms) Result: • Flexibility helps ensure that all patients receive the treatment best suited to their needs • Precise treatment delivery maximizes dose to target while minimizing dose to healthy tissue, improving patient outcomes • Rapid image acquisition and treatment delivery enhance workflow and allow clinicians to treat more patients, increasing financial rewards

“This system is the future of radiation oncology.” William Russell, MD, Medical Director, Pennington Cancer Center, Baton Rouge General Medical Center, Baton Rouge, LA, USA

throughput – even complex treatments such as IMRT can be accomplished in ten minutes – allows them to treat more patients in a day. “If you have 35 patients undergoing treatment and you shave off 120 seconds from each patient, that’s more than an hour saved every day,” Smith says. “From an administrator’s perspective, that means we can treat four or five more patients in the same amount of time.” He adds that having a single system that can accomplish multiple tasks reduces staff training costs as well as engineering, maintenance, and vault costs. Russell points out that the installation of a technologically advanced linear accelerator is tangible evidence for the general public and physicians that Pennington Cancer Center is committed to excellence. “Physicians know that we have the ability to deliver highly sophisticated treatment plans with a state-ofthe-art Siemens solution,” Russell says, “and that has certainly resulted in more patient referrals to this facility.” Smith says he is confident that ARTISTE will retain its value over time because it is a

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platform for which Siemens is continuing to develop technology. Upgrades currently available include diagnostic CT imaging in the treatment room with the CTVision™ solution. Smith also anticipates future advances such as kVision™ Kilovoltage Cone Beam Imaging2, which delivers excellent 3D soft-tissue contrast, particularly for pelvic and thoracic targeting, and DoseGuided Radiation Therapy (DGRT)™ Solution2. “ARTISTE is cutting edge now and it’ll still be cutting edge next year, the year after that, and for years to come,” Smith says. 2

kVision Kilovoltage Cone Beam Imaging and DGRT Solution are works in progress and are not commercially available in the U.S.

Sameh Fahmy, MS, is an award-winning freelance medical and technology journalist based in Athens, GA, USA.

Further Information www.siemens.com/ARTISTE

Molecular Imaging

Thinking Outside the Box Offering better return on investment and workflow efficiency, Siemens Healthcare unveils Molecular CT – the next evolution in multimodality imaging. More than just a hybrid, Biograph mCT is the imaging crossover that will drive change in the way hospitals think about integrated imaging. By Claudette Yasell, MBA

Siemens Healthcare recently invited imaging opinion leaders from around the globe to discuss the future of integrated imaging and showcase an innovative new Siemens solution: Biograph Molecular CT – mCT. As the first scanner developed specifically for an integrated imaging environment, Biograph mCT sheds light on how to maximize workflow efficiencies while improving diagnostic capabilities for better patient care. “As the forerunner in integrated imaging solutions, Siemens wants to lead the evolution of PET·CT [positron emission tomography – computed tomography] to

maximize these innovations in imaging and make them available where they will have the most impact. What we’ve done with Biograph mCT is taken the best Siemens has to offer in CT and enabled the introduction of ’smart‘ contrast – molecular contrast – using the most advanced PET technology available,” says Bernd Montag, CEO of Siemens Healthcare’s Imaging and IT Division. While hybrid imaging is not new to molecular imaging experts, the availability of molecular contrast in radiology opens doors to increased cooperation and, potentially, new standard protocols that provide diagnostic information which is unachievable using independent imaging modalities. Financially, using one all-encompassing scanner can make the most of an institution’s imaging equipment and strengthen the existing workflows between radiology and molecular imaging; all of which target the patient as the ultimate beneficiary.

Smaller Footprint, Larger Impact Biograph mCT was designed to obtain functional, anatomical, and molecular information from one noninvasive diag-

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Molecular Imaging

Summary Challenge: • Obtaining functional, anatomical, and molecular information in a fast, efficient, and economical way Solution: • Adding advanced PET functionality to a premium CT system • Placing PET·CT in the radiology suite • Enabling molecular contrast in radiology

Patient-centric The ability to provide a high-quality imaging environment for patients that is accommodating, comfortable, and reliable plays a key role in the success of a hospital’s imaging center. The investment made in imaging equipment such as this will provide physicians the information necessary to better diagnose and treat patients. With this innovation, patient care can also be optimized. With the fastest PET acquisition times available and ultrafast CT scanning, patient movement is decreased, leading to better image quality. In addition, higher patient comfort is achieved due to shorter scan times. Biograph mCT also offers low-dose scanning1 in both PET and CT; a very important feature in imaging, as more concerns are raised with respect to radiation dose and increased frequency of tests.

Result: • Increased return on investment on imaging equipment • Maximized workflow efficiencies and patient comfort • Improved diagnostic capabilities for better patient care

nostic exam. Using Siemens premium CT technology, it adapts to virtually any patient and any clinical need with higher resolution, contrast, and speed. Biograph mCT comes together in one powerfully small package. It boasts a large bore, short tunnel, and small footprint for unparalleled patient care and comfort. Biograph mCT is offered with up to 128 slices. With a table that can accommodate patients up to 500 pounds (227 kilograms), it makes the technology available so that many more patients can benefit from the valuable information it provides. In addition to cutting-edge CT technology, Biograph mCT maximizes the most advanced PET technology available, including features such as a 33-percent increase in the PET field of view, highdefinition imaging technology with increased spatial resolution, and time-offlight functionality. It offers the ultimate

nosing disease earlier and of more effectively managing disease at reduced costs. “And speaking directly to the bottom line,” says Montag, “with Biograph mCT, an institution may only need to purchase one imager instead of two, representing a huge cost savings potential at a time when healthcare budgets are tight.” Replacing a two scanner purchase with just one can lead to savings in space, construction costs, operating costs, and life-cycle costs. This scanner is also upgradeable to higher slice configurations and increased molecular capabilities such as high-definition PET and time-of-flight capabilities, so the investment made today stands firm well into the future. A smart new solution, Biograph mCT offers increased benefits for patients and represents an intelligent solution for physicians and administrators who want to provide the best patient care available and get the most out of their investment.

in PET image quality and count rates for faster, more comprehensive scanning. It can complete routine five-minute PET scans, which provide maximum patient comfort and workflow efficiency. Applications in oncology include the ability to delineate lesions for diagnosis, staging, and restaging of cancer, providing exquisite anatomical detail plus a measurement of cell metabolism.

Optimizing the Gold Standard The first choice in imaging diagnostics, CT provides ultimate imaging capabilities in anatomical and functional evaluations. Historically, radiologists were first able to visualize anatomical structures using axial CT, then spiral, multislice, and now Dual Source and adaptive CT. They have come to rely on the wealth of information provided by the growing speed and evolving capabilities of dynamic CT. In fact, 28 million CT scans were completed in the U.S. in 2006 for oncological evaluations, making CT the most widely used technology to offer insight into diagnosis and treatment for cancer.2 But as the prevalence of diseases and conditions such as cancer and heart disease increases, the question becomes, “How can we offer even better diagnostic information with CT?” Currently, information from CT scans can visualize abnormalities such as blood clots, cysts, fractures, infections, and tumors in internal structures (for example, bones, muscles, organs, and soft tissue). CT is also used to guide the placement of instruments within the

Working Better Together This type of imaging innovation and integration is taking a front-row seat in the eyes of hospital administrators. Facilities can boast major cost savings, return on investment, and excellence in patient care as well as patient and staff satisfaction when innovation and integration are optimized. The establishment of new paradigms such as molecular CT for integrated imaging diagnostics using state-of-the-art CT and PET technologies allows patient data to flow seamlessly and swiftly among departments, harmonizing departmental cooperation. Biograph mCT is the quintessential definition of efficiency: one team, one room, one machine, and one comfortable patient. It offers the potential of diag1

Data on file

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IMV 2006 CT Market Summary Report

Molecular Imaging

body, for example, to perform a biopsy. The addition of an iodine contrast agent also allows organs and structures to be seen more visibly. And with the latest CT technology, tumor perfusion is also possible.

proven to change the management of oncology cases. Using colorectal cancer as a prime example, PET·CT changed the management of the disease in 66 percent of patients, and additionally, new disease was found in 43 percent of the cases.3 Using a radiolabeled tracer, or molecular imaging agent, physicians can visualize metabolic information in tumors from initial diagnosis through the patient’s treatment and follow-up care. The most common molecular imaging agent, fluorodeoxyglucose, or 18F-FDG, is used to illustrate metabolic activity within cancerous tumors. Unavailable using CT alone, information from the molecular imaging agent in conjunction with the PET scan can also determine if metastases are developing as a result of the primary cancer. This information can be pivotal in the management of disease, as this type of metastatic activity may be too small to be seen on conventional CT. Other imaging agents are currently in the process of being developed. These agents are being created to capture disease-specific information. There are also a number of imaging agents being developed that can differentiate between

Crossing Over to Molecular Resolution Obtaining even better diagnostic information comes not from the ability to visualize a tumor or abnormality through the use of a contrast agent, but from the ability to delineate the metabolic activity within the tumor and to determine whether or not it is responding to treatment. To move oncology forward, CT will break out of being a black-and-white modality and capture this type of information through the use of a molecular contrast agent. This concept, using molecular contrast with PET and CT, has been applied in the molecular imaging arena with unprecedented success. “For years now, we’ve seen how molecular imaging has influenced the diagnosis and treatment of cancer. Hybrid molecular imaging with PET·CT has made significant inroads in everything from diagnosis and staging in oncology to determining the effectiveness of cancer treatments. It has even been used in the development of new drugs,” says Montag. The information offered by cellular molecular activity using PET·CT has been

3

active and inactive tumor cells within a single tumor, to help the radiation planning physician determine where to best target therapy. The correlated PET·CT images provided in a multifaceted imaging environment offer a level of information not previously available. Taking this information and applying it in a new arena, asserting that every CT can have molecular imaging capabilities, clearly addresses the need for more effective imaging in oncology and makes it more widely available; offering personalized and very specific information about patients’ disease. So many advances are being made in the development of imaging agents that the most commonly used imager for oncology studies – CT – should be better equipped to handle them. Claudette Yasell holds an MBA from Dominican University, River Forest, IL, USA.

Further Information www.siemens.com/mCT

Scott et al. PET Changes Management and Improves Prognostic Stratification in Patients with Recurrent Colorectal Cancer: Results of a Multicenter Prospective Study. J Nucl Med, 2008; DOI: 10.2967/jnumed.108.051615

“What we’ve done with Biograph mCT is taken the best Siemens has to offer in CT and enabled the introduction of ‘smart’ contrast – molecular contrast.” Bernd Montag, CEO, Siemens Healthcare, Imaging & IT Division, Erlangen, Germany

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Facility Planning

Facility Planning The Mazankowski Alberta Heart Institute’s development centered on patient experience. One result: a healing garden at the center of the institute for patients to enjoy a relaxing atmosphere.

Canadian Innovation with Heart With the support of Healthcare Consulting, Siemens is helping a new state-of-the-art cardiac care and research institute in Western Canada to set new standards of care. Their approach is simple: clinical and operational transformation. Their efforts will not only transform the medical options available to patients, but also the way in which healthcare providers approach patient care. By Richard Cairney

Facility Planning

“Healthcare Consulting took it all down to what’s best for the patient.” Carol Manson McLeod, Senior Operating Officer, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada

Summary Challenge: • Identify performance measures and introduce technological and architectural improvements to support a patient-centered culture in a new cardiovascular institute Solution: • Employ Healthcare Consulting with its portfolio of room and functional planning, IT & technology consulting, process and performance optimization, concepts to increase patient satisfaction, and patientcentric care concepts • Examine existing and planned cardiology practices as they relate to patients and introduce technological, structural, and cultural changes to the way care is delivered Result: • Intensive Care Unit constructed in a way that provides patient and family privacy while reducing the risk of spreading infection • Integrated bedside terminals that allow for easier admitting, physician’s access to electronic patient records, and patient education • Decentralized nursing stations and wireless communication devices that eliminate stress-inducing overhead pages, bringing patients and the care team closer together • Coaster-sized pagers that allow clinic patients a new degree of freedom when waiting for treatment • A sea change in culture necessary to deliver patient-centric care

The 600,000-square-foot Mazankowski Alberta Heart Institute in Edmonton, Alberta, Canada, is one of few North American heart institutes to handle both pediatric and adult patients under one roof. It will take on the most challenging cases, including transplants and artificial hearts, and houses a world-class cardiac research center to help speed the benchto-bedside process. Other innovations include hybrid operating rooms where cardiologists and surgeons, armed with the latest medical technology, will work together to conduct minimally invasive procedures, while being prepared to change course and conduct a more invasive procedure if necessary. The publicly funded Heart Institute, adjacent to the University of Alberta Hospital, the Stollery Children’s Hospital and the University of Alberta itself, will reduce patient wait times for clinical visits and surgical cases visits, meeting new guidelines established by the Canadian Cardiovascular Society. The former waiting time for nonurgent cardiac surgeries was about 14.7 weeks, and the new benchmark is six to eight weeks; the urgent outpatient electrophysiology waiting list of 120 days is expected to be cut dramatically, to 14 days. The new facility offers greater capacity – it is estimated that it could handle 600 to 700 more surgeries annually, up significantly from the 1,140 it performed during the past year. Beyond increasing capacity to its community, the Heart Institute represents a radically different type of treatment center. By bringing diverse disciplines and

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opinions together, the new institute will be changing the very culture of cardiac care. And while the institute is equipped with the very best in medical technology, it is also designed to achieve a gold standard of care, where patients’ needs come first. “The most difficult thing is to get people to think outside the box,” says Carol Manson McLeod, the institute’s Senior Operating Officer. Healthcare Consulting, she says, has helped manage change and inspire a cultural shift. “The Healthcare Consultants helped people start thinking of ways they can do things differently – so the solutions are homegrown.” Prior to the institute’s opening in 2009, some of the challenges practitioners faced were the result of their efforts to provide innovative treatment in the previous location, which created high demands on the existing space. “We had been scaling up our capacity to provide new services and increase volumes in the same space,” says Patient Care Manager Terry Hogan. “We added a lot of new services and new concepts that required new staff. Everyone was vying for the same space to do their work.”

Patient-centered Care The leadership team at the Heart Institute recognizes that moving into the new institute in 2009 involves much more than simply new equipment or treating patients the same way with more room. It means a sea change in the way the institute cares for patients. Siemens has installed one single-plane and two

Facility Planning

biplane cath labs, as well as a magnetic resonance imaging (MRI) system. While this technology provides patients with the highest diagnostic capability on the market today, the Heart Institute engaged Healthcare Consulting to work with the team. Siemens experienced healthcare professionals helped to develop optimized workflows, where processes are refined and technology levers are planned. In addition, the facility was designed to create an environment focused on the highest quality of safe patient care, efficient utilization of valuable resources, and a positive experience for cardiac patients and the care team. The mutual goal was to create a center of excellence and an environment where optimized, patient-centered processes are in place. Nurses, for example, will carry wireless phones to eliminate overhead pages. This enables patients to contact nurses directly. In clinics, coaster-sized pagers will be given to patients, allowing them to leave the waiting area. “They’ll be able to go anywhere they want to without worrying about missing their appointment,” says Patient Care Manager Donna Daniec. Nursing stations, traditionally the hub of a treatment unit, have been removed. Instead, nurses are situated at alcoves adjacent to patient rooms, according to Daniec. “We’re taking everything we need to care for the patient directly to the patient,” she says. “When you look at the spectrum of inpatient and outpatient care, we were making patients travel around to get the services they needed.” Even information will be brought directly to patients via bedside terminals provided by Siemens, says Manson McLeod. “We’ve talked about being more focused on the patient. We want to do the same thing if you are a planned or unplanned admission. If you’re coming from a clinic and need to be admitted, you would normally have to go hither and yon to find admitting. But with the terminals, we’re able to provide bedside registration – the patients will actually be admitted at the bedside in their room,” she says. “In the future, we’ll even be able to have access to electronic patient records at the bedside terminals.”

With the greater space and improved workflows, the Heart Institute hopes to handle 50 percent more cardiac surgeries and thus, reduce wait times for patients.

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Facility Planning

“We’re taking everything we need to care for the patient directly to the patient.” Donna Daniec, Patient Care Manager, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada

Turned to Siemens to help optimize the University of Alberta’s new cardiac hospital (from left): David Johnstone, MD, Clinical Director; Donna Daniec, Patient Care Manager; Terry Hogan, Patient Care Manager; Carol Manson McLeod, Senior Operating Officer

The Heart Institute is working with Siemens to develop a system in which doctors can call up a patient’s medical images on the bedside screen to explain diseases and treatment plans. “The bedside terminal is a device for us to teach our patients – we are uploading teach42 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

ing materials onto the system and at the same time, we’re uploading the same content on our website so that what they see on the screen at bedside is what they will be able to see from home, after they’ve been discharged,” Manson McLeod explains. The terminals will also serve as the patient’s television, telephone, and allows them to surf the net or communicate via email. She acknowledges that some patients will be tentative about using the technology, but adds that the patient-centric outlook at the institute will help them become comfortable with it. “We are going to make sure that all the members of our staff and volunteers – from housekeeping to nutrition personnel – are able to help patients use this technology.”

Designed for Safety, Comfort, and Synergies Manson McLeod credits Healthcare Consulting with helping ensure that the institute adopts a commitment to patient care that is embraced by all staff. Advice from the Consulting team even resulted in a significant architectural change in design of the Intensive Care Unit (ICU). Initially, part of the ICU was to be built in a traditional way, with eight of the beds sharing a common space. But with new concerns about infectious disease,

Facility Planning

“Having kids under the same roof really changes the focus of the institute, in that you need to pay attention to their unique needs.” David Johnstone, MD, Clinical Director, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada

Siemens suggested a design change. “The Healthcare consultants looked at our ICU, and even though we were in the midst of construction, the organization agreed that it was important enough to make the changes,” Manson McLeod says. “Healthcare Consulting took it all down to what’s best for the patient.” That’s not surprising, considering that the priority on the patient experience was at the forefront of many other elements in the design of the building, which does not resemble a traditional hospital. Every patient room, for example, has natural light coming either from exterior windows or from the institute’s indoor Healing Garden – a placid environment that has an immediate soothing effect. Steps are being taken to improve the experience of outpatients, too. “Siemens was very influential – they helped us deal with some fundamental issues,” adds David Johnstone, MD, Clinical Director for the institute. Armed with a worldwide perspective and experience, Healthcare Consulting helped the institute develop performance indicators. “They got us thinking on that level, and as a result, we’ve adopted targets for our services, allowing information to drive policy.” Johnstone notes that the institute’s location, at the heart of Edmonton’s nationally respected health and medical research

center, is another of its strengths that lends to its distinct nature. Many cardiac patients, for example, are also diabetics. The Heart Institute has the advantage of being affiliated with the Alberta Diabetes Institute, a world-leading diabetes research center. Similarly, the institute and University of Alberta Hospital are attached to the Stollery Children’s Hospital. “Having kids under the same roof really changes the focus of the institute, in that you need to pay attention to their unique needs and not just replicate what is done in the Stollery,” he says. Johnstone adds that the focus on patient needs is also being applied through new services designed to keep patients close to their home communities. The Heart Institute serves a population scattered across a vast geographic area, with some patients coming from remote settings. “Heart clinics work, but does it make sense that patients have to wait months for an appointment and need to drive several hours to get here?” he asks. “Is it fair that they have to park so far from the building that they’re having chest pain by the time they make it through the door?” Telehealth sessions solve some problems, and Manson McLeod says the institute’s staff is brushing up on the principles of adult learning in order to eliminate eight-

Bedside terminals are used for everything from patient admission to patient education and entertainment, to file replacement during ward rounds.

hour days for patients in presurgery assessments and education. “We were doing that because it suited us – not the patient,” she says. “The Healthcare Consultants helped us to change our way of thinking. We’re now creating a culture where we think of the patient first. We are on the cusp of some fundamental changes.” Medical and technology writer Richard Cairney also serves as the Communications Officer for the Engineering Faculty at the University of Alberta in Edmonton, Alberta, Canada.

Further Information www.siemens.com/ healthcare-consulting

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Nurses have immediate electronic access to each patient’s examination and test results. Barcoding helps prevent risks for patient safety.

Med Meets IT at MedCentral MedCentral deployed a complete Siemens solution suite across its entire enterprise in an effort to increase patient safety and decrease costs through operational efficiencies. It ended up with even more, including dramatic improvements in workflows, processes, and interdisciplinary care. By Kevin Self

‘Med Meets IT’ is the concept of seamlessly blending two independent fields – medicine and information technology – into a single, fully-integrated, harmonious solution that is easily accessible and conveniently deployed in a clinical setting, resulting in cutting-edge efficiencies and patient safeguards that were not even possible in healthcare until recently. Competition in today’s healthcare markets is fierce. As consumers become more informed and begin shopping for hospitals, health systems are forced to re-

examine their operations to find new ways to introduce efficiencies and position themselves as world-class organizations. As anyone involved with healthcare management knows, this is easier said than done. Add regional and statewide competitive pressures into the mix and it is enough to make even the strongest provider turn and run quickly in the other direction. For this reason, it is all the more impressive when – despite mounting obstacles – a mid-sized, regional health system

44 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

demonstrates forward-thinking innovation to gain competitive advantage. Meet MedCentral Health System, a nonprofit health system located in Mansfield, Ohio, U.S., that services a city population of approximately 50,000 and a countywide potential patient pool of nearly 120,000. With 351 beds, 2,600 employees, two hospitals, and four other local facilities, MedCentral is situated between Cleveland and Columbus – larger cities home to two of the country’s best cardiac treatment centers. So how is MedCentral

Integrated Healthcare

able to compete to the point of earning a number one state ranking by HealthGrades1 for its cardiac surgery program? The answer to this question resides in a number of system-wide solutions, but there is no debate that the organization’s IT initiatives are at the heart of its recent rise to the top. With its tagline of ‘Expert Care, Close to Home,’ MedCentral epitomizes the concept of Med Meets IT across its entire enterprise.

Expert Care, Close to Home Physicians practicing at MedCentral are more confident by the ability to deliver accurate information to the right person at the right time. Repeat patients are delighted they do not need to re-do paperwork before admission. Clinician recruitment and retention have never been higher. All are recent benefits of a strategic effort to improve patient safety. But this was not always the case. Four years ago, MedCentral was essentially in the dark ages as far as fully utilizing IT to deliver better patient care. The entire health system was operating on a manual, paper-based system, and the technology it had in place offered limited deployment and integration capabilities. When its financial system was nearing sunset at the end of 2004, MedCentral started looking for other solutions. The need to replace a single system quickly grew from a simple upgrade into a much larger initiative. “We wanted to find a solution that could replace our financial system, but also expand to encompass all of MedCentral Health System’s needs,” says Chief Executive Officer James E. Meyer. “We wanted to enhance our ability to use IT to improve patient care and safety, and provide clinicians with better data at the point of care.” Enter ’Project Expert Care’ – MedCentral’s system-wide IT initiative.

’provide clinicians with better data, more efficiently, and at the point of care.’ None of these goals were achievable with the old paper-based systems. In 2004, MedCentral was inefficient and relied too heavily on manual processes that exposed the health system to human error and excess costs. And it was not an isolated problem. Nearly every department was plagued by delayed laboratory results, inaccurate data entry, or lost images. This environment was not conducive to maximizing quality patient care. In radiology, MedCentral was still handsigning reports, and it was not uncommon for physicians to wait as long as 48 hours to receive them. In the laboratory, labels were printed and manually sorted – waiting 17 hours for hard-copy test results was considered acceptable. The same was true for nursing, where the staff was spending inordinate amounts of time manually extracting data from records to accommodate MedCentral’s reporting obligations. The objectives of Project Expert Care were simple: increase patient safety through improved workflow and decrease costs through greater operational efficiencies. The answer was to build an

enterprise-wide solution suite that would embrace the entire spectrum of care.

A New Nervous System After an extensive evaluation of multiple healthcare IT vendors, MedCentral selected Siemens for two primary reasons: its vision for the future and its robust technology offering. “We bought into Siemens philosophy of Med Meets IT because it was extremely compatible with where we wanted to go in the future,” says Michael Mistretta, Vice President of Information Services (IS) and Chief Information Officer at MedCentral. “MedCentral’s decision to go with Siemens has been validated many times over. The incorporation of clinical and imaging data at the point of care has been almost transformational in our delivery for patients.” In addition to similar overarching philosophies, the tactical approach to developing a quality, state-of-the-art IT solution was the same – taking an enterprise approach over best-of-breed. The two new partners decided on a comprehensive Siemens solution that included Soarian® Clinicals and Financials, syngo® Suite, a picture archiving and

Redefining Expert Care If there was a single mantra for those involved with Project Expert Care, it was 1

Health Grades, Inc. is a U.S. healthcare ratings organization, providing ratings and profiles of hospitals, nursing homes, and physicians.

Thanks to Project Expert Care, MedCentral’s cardiac surgery program earned a number one state ranking by HealthGrades.

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Integrated Healthcare

communication system (PACS) and radiology information system (RIS), Patient Identification Check, NOVIUS® Lab, Med Administration Check (MAK), and Siemens Pharmacy. “Workflow was the backbone of the Siemens philosophy and one of the greatest successes of Project Expert Care. Siemens helped us to look at our workflows, how we were operating, and how Soarian would impact those workflows,” says Claudette Brown, RN, BSN, and Clinical Applications Manager in the IS department. Brad Peffley, Vice President of Clinical Services, agrees. “We used Siemens consulting services along with our own staff to tear apart our existing processes and look at ways we could gain the biggest advantage from the new system.” Although the initiative elevated the role of the IS department, senior management made it clear this was more than a technology upgrade. Project Expert Care was a system-wide initiative that was integral to the future of MedCentral. “IT itself doesn’t touch a patient or deliver care, but it’s the nervous system for all the different activities involved with

patient care,” says Fred Crowgey, Projects Director for IT. MedCentral’s nervous system – its core for patient care delivery – was Soarian Clinicals. “Soarian made us nimble and made results available in a timely manner,” says Michael David Patterson, MD, Vice President of Quality and Performance Excellence and Chief Medical Officer. “Before that, we were reporting lab work on a paper. Nurses then used that paper chart for documentation. And the same was true for medications – we used a paper MAR [medication administration record]. It is hard to believe we were operating like that – and it was only a few years ago.”

Maximizing Efficiencies in Patient Care As part of Project Expert Care, one of the first metrics baselined and monitored – as an indication of the efficiencies MedCentral hoped to gain from the Soarian solution suite – was reducing length of stay (LOS). In 2003, the average LOS was 5.4 days. Today, that number has been reduced to 4.6 days – the equivalent of having an

extra 30 to 35 beds annually. Plus, MedCentral’s patient volume is 60 percent Medicare/Medicaid, which means dealing with diagnosis-related group (DRG) reimbursement. Under DRGs, the facility receives a set dollar amount regardless of the amount of time a patient stays in the hospital. “If we can safely discharge patients – safety being our primary objective – each day that we can reduce that stay is a dollar savings for the organization,” says Janene Yeater, Assistant Vice President for Accreditation and Utilization Management. “Soarian, in part, enables us to speed that delivery of care, helping to directly improve our bottom line.” One of the biggest benefits of Soarian Clinicals is rapid access to test results, particularly radiology reports and laboratory results. The turnaround time in radiology improved dramatically when MedCentral moved from film to Siemens syngo Suite for RIS and PACS. Prior to the implementations, its average time for a final report was 24 hours – although 48 hours was not uncommon. Immediately after implementing Siemens digital imaging systems

A Microcosm of Project Expert Care: The Emergency Department There is little doubt of the impact that Soarian and other Siemens solutions have had across the MedCentral enterprise. This, in fact, can be realized simply by examining its Emergency Department (ED) – an ideal microcosm of the benefits and efficiencies realized through MedCentral’s greater Project Expert Care initiative. The ED is a primary patient entry point where data capture is essential, as well as one of the most stressful and fastpaced areas within any hospital. Small inefficiencies are amplified within the ED and can lead to problems further down the continuum of care. As such, it was a focal point at MedCentral when implementing its Soarian solutions. Here are some of the efficiencies realized: • Reduced ED capacity from over 100 percent to around 85 to 90 percent • Reduced triage-to-admission time from almost eight hours to 4.5 hours

• Reduced triage-to-discharge time from more than five hours to 3.2 hours • Eliminated the pre-implementation practice of boarding patients – some intensive care unit patients – in the ED MedCentral’s ED also continues to invest in IT solutions, the most recent being the Emergency Department Tracking Board, which provides ED clinicians the ability to automate portions of the admissions process. For example, if a patient is admitted in the ED and needs an X-ray, clinicians simply enter the appropriate data and Soarian will automatically send a notification to radiology. The radiologist, in turn, can monitor the ED Tracking Board to assess the incoming caseload from the ED – introducing time efficiencies and workflow improvements. The ED’s end result – representative of the greater MedCentral enterprise – is improved patient safety, decreased costs, and better overall quality of care for the patient.

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and PACS throughout the Radiology Suite, turnaround time was reduced to six hours. In recent months – despite the retirement of a radiologist and taking on volume from MedCentral’s outpatient center – turnaround time was further reduced to an average of two hours while maintaining quality levels. “With PACS and our voice recognition software, the final validated radiology report – not the preliminary report – many times beats the patient back to the room from the X-ray department,” says Patterson. The story is the same for transcriptions. Despite moving all transcriptions inhouse and adding the volume from another facility, Siemens solutions enabled a reduction in radiology staff from six fulltime equivalents (FTE) to 4.5 FTEs. “Without a doubt, the PACS solution of syngo Suite has made radiology more efficient and drastically improved our throughput,” says Peffley. According to Patterson, the same trend can be found examining the NOVIUS Lab implementation, which is a testament to the integration planning of the deployment. MedCentral’s laboratory is comprised of many independent systems and instruments operating in two different facilities, including an ADVIA WorkCell® CDX Automation Solution with ADVIA Centaur® Immunoassay Systems, ADVIA® 1800 Chemistry Systems, and ADVIA CentraLink® Networking Solution. With these Siemens solutions in place, “Laboratory results are completed within an hour or two. Before the implementation, it was 24 hours before a physician could even look at that result.” The reduction in turnaround time enabled the lab to increase its labor efficiency as well. The number of lab procedures completed prior to the implementation was 9,975 per FTE. After the implementation, this metric jumped to 10,791 per FTE – almost a ten percent increase in productivity. In addition, all data is automatically verified before it is forwarded to Soarian Clinicals, helping to assure consistency and increased quality in the results review process, further enhancing patient safety. “One person can now do the work of two under the old system,” says Debra

Real-time information on their handhelds helps ensure phlebotomists know about test changes – and provide the correct sample at the correct time.

Ruckman, Phlebotomy Supervisor. In the end, these efficiencies in the lab add up to better and more timely care for the patient. “Our physicians now have greater expectations for lab results and availability. The effect is a completely different interaction with the lab,” says Terry Weston, MD, Vice President of Physician Services. “The conversation is not ‘where’s the report and when will I get it,’ but rather physicians are free to ask deeper questions and explore other possibilities.”

Enterprise Cost Reductions The solutions now in place at MedCentral enable direct (i.e. reduced material costs) and indirect (i.e. time efficiencies) cost savings across the enterprise. The radiology department offers textbook examples of both. By transitioning from a film-based system to PACS, MedCentral has eliminated the cost of film almost completely. Within the first month of implementation it was 95 percent filmless. This translates to an annual savings of about US$450,000. What is more, that number does not include the additional savings of chemicals, canceled maintenance contracts, and other ancillary costs associated with film. MedCentral has also realized indirect cost savings in radiology, including the elimination of transcription services,

as well as the intangible benefits of Siemens RIS/PACS integration. “The integration of RIS and PACS saves us from doing many mundane tasks,” says Philip Calendine, MD, Chair of the Department of Radiology. “When we select a patient name from our worklist, all the demographics and patient information is automatically transferred. There is no manual data entry. When you’re reading 200 to 250 studies every day, saving an extra 20 seconds per study translates to hours over the course of a week.”

Automating Patient Safety Patient safety was the underlying reason for Project Expert Care, and no two solutions implemented at MedCentral are more directly associated with patient safety than the Siemens barcoding solutions: Patient Identification Check and MAK. “Prior to go-live with Patient Identification Check, I would do three or four disciplines a month with people misdrawing a patient,” says Project Expert Care Director Crowgey, also formerly the Lab Director. “For the first year after implementation, in every place that Patient Identification Check was used, I didn’t do a single discipline.” In fact, since the implementation of Patient Identification Check in March 2006, there has not been a single patient identification error. This is due,

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Integrated Healthcare

Summary Challenge: • Inefficient and time-consuming paper reporting system • Inadequate paper-based documentation • Increased risk for patient safety due to human error in manual processes • Medication errors that threatened patient safety • Excess turnaround times for lab and radiology reports • High costs associated with filmbased imaging technology • Extensive back-logs in the Emergency Department Solution: • Siemens Soarian Clinicals workflow management technology enables best-practice implementations and continuing process improvements • NOVIUS Lab streamlines and standardizes laboratory processes, reducing turnaround times • An ADVIA automation system, along with ADVIA chemistry and immunoassay systems, and the ADVIA CentraLink data management system automates the laboratory • Patient Identification Check automates patient safety through point-of-care barcoding technology – helping ensure the five rights of patient safety • Med Administration Check (MAK) automates medication administration through pointof-care barcoding technology – helping ensure the five rights of medication administration • syngo Suite improves communication through the use of complete imaging management workflow, increasing efficiency and access to digital information

in large part, to the quick adoption of the technology by phlebotomists. “We had a strict policy for labeling tubes among the phlebotomists – basically three strikes in a year and you’re out,” says Crowgey. “They quickly recognized that using technology would preserve their jobs, as well as help reduce the potential to make an error.” Patient safety is also reinforced by using mobile devices, according to Karen Phalor, ASCP, an IT analyst and medical technologist at MedCentral. “By simply using their handhelds, phlebotomists can be fed real-time data when there are changes or tests added – this enables the correct sample at the correct time.” If Patient Identification Check is the safety net for patient identification – satisfying the five rights of patient safety – then Med Administration Check (MAK) is the equivalent for medication – satisfying the five rights of medication administration. Patient Identification Check coordinates the efforts of the lab with that of the phlebotomists. MAK coordinates the efforts of the pharmacy with that of the nurses. The data generated shortly after go-live with the integrated Siemens Pharmacy and MAK solution speaks volumes to the layer of safety the technology provides. “The first week that we launched the solution, we caught 383 medication errors – the wrong patient about to receive the wrong medication, or about to receive it at the wrong time, or at the wrong dose,” says Patterson. “That was a humbling experience. I can’t imagine a healthcare system even considering a future without something like Pharmacy MAK in place.”

Core and Quality Measures MedCentral has seen a dramatic turnaround in its ability to share information because of Soarian. “Our core measures have improved so much that we’ve not only hit our goals, but we’re also talking about raising the bar,” says Patterson. “You can pick any core measure and I can directly relate how Soarian assisted with that quality-of-care improvement.” When MedCentral first started capturing core measurement data:

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• Acute myocardial infarction (AMI) was in the 50th percentile. Today, MedCentral is at 93 percent • Pneumonia was in the mid-30th percentile. Currently, is it at 90 percent • Congestive heart failure was one of MedCentral’s lowest baseline scores. Currently, it is at 94 percent “We’re on the upper level of our stretch goal for congestive heart failure and looking to extend that beyond the national average,” says Michael Schwartz, Executive Director of Cardiovascular Medicine, and adds that the functionality and flexibility of Soarian Cardiology – Siemens cardiovascular information solution – and syngo Dynamics – Siemens cardiology PACS – have also helped recruit and retain the best cardiologists. The department is a source of pride for MedCentral. In 2007, 2008, and now also for 2009, HealthGrades named its cardiac surgery program the best in Ohio – awarding it a Number One ranking. In an effort to enhance reporting functionality to the already robust Soarian offering, MedCentral recently launched Soarian Quality Measures, which will streamline the quality improvement process by automating chart abstraction and help expedite the submission of quality measures – as defined by the Centers for Medicare and Medicaid Services and The Joint Commission.

Interdisciplinary Care The ability for various departments and disciplines to work together and easily share information was a priority from the beginning – the primary reason for taking an enterprise approach to Project Expert Care. “When we examined the Soarian solution from an integration perspective – bringing together pharmacy, lab, radiology, et cetera – it was our top pick,” says Phalor. Clinicians at MedCentral credit two features of the Soarian implementation for enabling this interaction: the functional screen and online access. The functional screen is part of the nursing admission assessment that identifies criteria points from each discipline. Nurses mark each criteria point exhibited

by a new admission. Soarian processes the completed functional screen and automatically prompts a consult referral to the relevant discipline. “The functional screen has been significant in improving our patient care, but it also helps decrease our length of stay,” says Joann Plaster, Vice President of Nursing and Social Work Services. “The sooner you can get all the necessary disciplines involved in the care, the faster that patient gets better.” In the first month of operation with Soarian’s rules and workflow technology – the system on which the functional screen is based – MedCentral saw a double-digit percentage increase in the number of consults delivered to the various disciplines. “This functionality also goes a long way with Joint Commission and other compliance reporting,” says Yeater. “This process is now automated and patient care is done consistently and in a standardized fashion, which directly impacts accreditation.” Access to information has been, perhaps, the single greatest benefit of the Soarian solution. “There’s a lot of data available that we didn’t have before,” says Peffley. “Whether it’s patient statistical information, departmental statistical information, or financial information and budget reports, I can get it myself and it’s available almost immediately.” The result is better communication between departments, particularly with the nursing and the medical staff. “Nurses have access to results immediately and electronically. The physicians – even from home – also have online access,” says Weston. “This is a vast improvement and makes a nurse’s reporting capability exponentially stronger and faster.” Expressing similar sentiments, Crowgey adds: “Online access to the right information at the right time improves patient care and supports faster clinical decisionmaking. It is just good quality patient care.”

A Foundation for the Future MedCentral, with its suite of Siemens solutions in place, is only beginning its

Turnaround time for radiology reports has decreased from 24 hours to two hours with the implementation of PACS and voice recognition.

Project Expert Care initiative. The health system already has plans to expand the use of existing technology to remote facilities and has a list of new technologies that are in some stage of planning. These include Computerized Physician Order Entry (CPOE), further utilization of its Emergency Department Tracking Board, Siemens critical care application, Soarian Plans of Care, Decision Support with embedded analytics, Soarian Cardiology and AXIOM® Sensis, Soarian Quality Measures, radio frequency identification (RFID) capabilities, and Soarian Health Information Management (HIM). “The goal is to have our entire enterprise on one Soarian system,” says Patterson. “Siemens will beat every other vendor and win the race to a complete enterprise solution. This is the secret to our great partnership. MedCentral will help Siemens to achieve that goal, because we want to be the first health system to implement the solution.” Kevin Self is a writer for Launch International, a company specializing in strategic marketing and sales enablement for technology companies.

Further Information www.siemens.com/syngo www.siemens.com/Soarian

• The PACS, part of syngo Suite, helps provide security as well as remote and easy access to archived digital images across various disciplines • The RIS, part of syngo Suite, enhances imaging communications to and from the radiology department and integrates seamlessly with the PACS • Soarian Cardiology and syngo Dynamics aid in moving from modality-focused to patientcentered care Result: • Workflow efficiencies resulting in reduced length of stays • Increased patient safety by automating processes and minimizing human error • Increased laboratory efficiency, decreased laboratory turnaround time, improved laboratory efficiency, and increased laboratory capacity • Significant improvements in core measures • Reduced costs through greater productivity and elimination of materials and outsourced services • Increased interdisciplinary communication • Enhanced accessibility to information

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Ultrasound

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Ultrasound

Tissue Strain Analytics – A Breakthrough for Ultrasound Liver Examinations A new era is dawning for quicker, more accurate diagnoses of pathologies in the liver, thanks to a research partnership between The University College London Hospital and Siemens Healthcare. By Nils Lindstrand

A member of the Siemens Healthcare Ultrasound Research Advisory Board, Professor William Lees, MD, of the University College London Hospital (UCLH), UK, started researching the clinical potential of ultrasound Acoustic Radiation Force Impulse (ARFI) imaging about one year ago. He soon realized that this technology might be a way to increase the clinical diagnostic information that results from conventional sonographic examinations. “Tissue Strain Analytics1 adds an independent parameter to our existing morpho-

logical diagnostic process. No single parameter is going to enable us to characterize tissue with any degree of accuracy, but the more parameters we have, the more confident our diagnosis can be,” says Lees of the emerging application. Virtual Touch™ Tissue Imaging1, the first commercially available implementation of ARFI, uses an acoustic ’push pulse’ to interrogate the mechanical strain prop-

1

This product is not commercially available in the U.S.

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A member of the Siemens Healthcare Ultrasound Research Advisory Board, Professor Dr. Lees examines the capabilities of Virtual Touch Tissue Imaging and Quantification in liver fibrosis.

Summary Challenge: • Obtain qualitative visual or quantitative value measurements of the mechanical stiffness properties of tissue Solution: • Tissue Strain Imaging allows visualization of differences in the stiffness of tissues and pathologies that may otherwise appear very similar using conventional ultrasound imaging • Tissue Strain Imaging has the potential for immediate results • Tissue Strain Imaging is userindependent Result: • Virtual Touch applications, together with conventional sonographic scans, may enable physicians to avoid unnecessary biopsies • Grey scale image presents a map of regions and localized areas which shows relative stiffness in the tissue • Numeric value provides a good understanding of the general condition of the tissue

erties or stiffness of tissue, a method similar to a physical palpation exam. Virtual Touch images provide complementary information to the standard B-mode image by supplying insights into changes in tissue stiffness, which are often associated with pathology. A Virtual Touch image is formed by applying a push pulse, which results in the relative displacement of tissue elements. The degree of displacement will vary with the specific stiffness properties. For example, soft tissue will experience greater displacement than very stiff tissue, which may displace a very small amount or not at all. Conventional ultrasound beams track the displacement of tissue. This information is compared to the baseline image, resulting in a qualitative elastogram, which visually represents the variation in stiffness within a region of interest. Today, this technology is only available by Siemens with the ACUSON S2000™ ultrasound system. “Virtual Touch Tissue Imaging is an important evolution of the ultrasound scanning technologies,” says Lees. “The technology works, it is reliable and robust. Virtual Touch Tissue Imaging has a minimal impact on the tissue, yet it has the ability to extract an impressive amount of vital information out of a single procedure.”

This is implemented by Virtual Touch Tissue Quantification1. Shear waves, which travel at greater speeds in stiff tissue compared with soft tissue, are generated, and travel perpendicular to the push pulse. While they do not interact directly with the transducer, their movement may be tracked by detecting tissue displacement perpendicular to the transmitted, conventional ultrasound beam. “It is like hitting a board on the upside and feeling the effect at the ends,” says Lees, “only with an extremely high accuracy in the measurement.” Virtual Touch Tissue Quantification may prove to be a major breakthrough in identifying early stages of liver diseases causing cirrhosis. In early studies, the application proved extremely sensitive in diagnosing fibrosis and distinguishing it from normal liver and cirrhosis. Conventional ultrasound, on the other hand, cannot detect fibrotic changes prior to cirrhosis. “We will need more data to determine whether this new technology is also capable of tracking progression of fibrosis or responses to treatment, but I am very optimistic that it will have this capability,” says Lees. The robustness of Virtual Touch applications is an important advantage of this method. “We have been examining obese patients during the clinical studies already completed, and Virtual Touch Imaging showed very good accuracy,” says Lees.

Breakthrough for Liver Examinations Another application of ARFI technology is the measurement of shear-wave velocity. 52 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

1

This product is not commercially available in the U.S.

Ultrasound

Lees stresses the advantage of Virtual Touch applications as a user-independent method. “Both with traditional physical palpations and preceding ultrasound technologies, it is easier than you would imagine for a physician to press harder to get the result he or she was expecting before the examination. With Virtual Touch applications, however, it is just pushing a button. You get the same accuracy every time, regardless of the operator, time, or expectations.”

A Way to Avoid Unnecessary Biopsies Virtual Touch applications may offer a way to reduce unnecessary biopsies and other invasive procedures otherwise needed to give an accurate diagnosis through easy evaluation of pathology. “These kinds of anomalies may be difficult to separate from malign tissue with other kinds of scanning technologies,” says Lees. “This is typical of how Virtual Touch Imaging is helping us: We can avoid many biopsies and other uncomfortable and unnecessary examinations.” Using this technology together with conventional sonographic scans and traditional biochemical examination, physicians may also be able to give a more reliable answer whether a pathology is malignant or benign. “I believe Virtual Touch applications will be an integral part of scanning procedures in the near future,” says Lees. “Our clinical tests up until now have shown a very high accuracy in separating malignant, benign, and healthy tissue. The method is quick and user-independent, and is totally unnoticeable for the patient.”

More Validation Needed “My present experience today is built on more than 200 cases,” says Lees, “and it indicates that Virtual Touch applications can detect fibrosis in an otherwise normal-appearing liver.” Now this needs to be validated against liver biopsy and biochemical testing for chronic liver disease. Experience shows that up to a thousand validated cases may be needed

to be able to define its role. Lees is convinced that Virtual Touch applications offer improved patient care on an individual basis. Physicians will be able to tell patients that they have nothing to worry about, or to proceed faster to additional examinations and treatment if this proves necessary. “The benefit of Virtual Touch applications is that we can be more convinced of doing the right things and giving correct information to the patient.” Lees and the UCLH are now organizing clinical tests for Virtual Touch applications, collaborating with a number of other clinics and hospitals in Great Britain. They will start as soon as the last details in the methodology are established and agreed upon. “We should be able to conduct these clinical tests within a couple of months,” says Lees. “We have already submitted an abstract to the European Congress of Radiology 2009 on Virtual Touch applications, and I think it will be sufficiently validated for wider clinical application towards the end of 2009.”

The interest for Virtual Touch applications has so far largely been confined to the liver. It may, however, prove to be a valuable tool also in examinations of other organs, for example, the kidneys and thyroid and maybe the lung. It will probably not work as well in rapidly moving structures such as the heart and vascular system. “Apart from this, we will need to establish a much larger database of Virtual Touch Tissue Quantification measurements in other diseases of organs,” says Lees. “I think it will be another year or two before we fully understand the potential of this technology.” Nils Lindstrand is a freelance business and technology writer based in Stockholm, Sweden.

Further Information www.siemens.com/strain

Tissue Strain Analytics at a Glance Tissue Strain Analytics is a new ultrasound application that enables visual or numerical measurements of the mechanical stiffness of tissue. This new dimension of information, which is not available using conventional sonographic imaging, represents the most significant advancement in ultrasound technology since the advent of Doppler imaging. Tissue Strain Analytics features three applications: • Virtual Touch Tissue Imaging allows clinicians to create a relative stiffness map (elastogram) for any region of interest. • Virtual Touch Tissue Quantification is the first and only application to provide a numerical value of shear-wave speed related to tissue stiffness at a precise anatomical location. • eSie Touch™ elasticity imaging, available on both the ACUSON Antares™ and ACUSON S2000 systems, enables high-resolution elastography using both superficial and endocavity transducers.

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In a busy hospital emergency department such as that of St. David’s South Austin Hospital, a part of St. David’s HealthCare in Austin, Texas, U.S., it is a race against time to diagnose acute coronary syndrome. Shearing unprecedented time off the diagnostic process contributes to faster, more appropriate therapy, better asset utilization and lower costs. Most importantly – it saves lives. By Diana Smith

Rush Hour ’Time is muscle‘ is a common adage among cardiologists, referring to the critical moments after a myocardial infarction (MI), or heart attack, when even minutes without intervention can translate into muscle damage. However, not all patients present to emergency departments with obvious MI symptoms. For these patients, the need to rapidly determine if a heart attack has occurred, obviously, is critical. Yet evaluation can be a clinical challenge when blood must be sent to a busy cen54 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

tral hospital laboratory where even immediate tests can take an hour or more. “Time is very much a factor in acute coronary syndrome [ACS],” says Steve Berkowitz, MD, Chief Medical Officer of St. David’s South Austin Hospital, a member of the St. David’s HealthCare system in central Texas. “When that coronary artery is blocked, the heart doesn’t receive blood flow to itself and it will fail as a pump in a course that would have dire consequences to the patient. The bottom line: Mortality improves when we can intervene faster, so that is our fundamental goal.” In an effort to speed up this critical time between diagnosis and treatment, administrators at the 252-bed facility turned

to Siemens Healthcare Diagnostics for cutting-edge technology that has transformed the way the Emergency Department delivers care for patients who arrive with atypical heart attack symptoms. The Stratus® CS Acute Care™ Diagnostic System with high-sensitivity assay capability has dramatically improved the time it takes to arrive at a diagnosis for patients with atypical symptoms, according to Berkowitz.

Increased Demand In Austin, the fourth-largest city in Texas, roughly the size of San Francisco, the St. David’s Emergency Department is one of the busiest in town, seeing more than 60,000 patients each year. Located south of the Colorado River in the self-pro-

claimed ’Live Music Capital of the World,’ the hospital is a certified Chest Pain Center accredited by the Society for Chest Pain Centers. Built in 1982, St. David’s South Austin Hospital completed a US$50 million expansion project in 2004. Today, its 42bed Emergency Department is divided into three areas of care: cardiac, examination, and fast track. “On average, we see 160 to 180 patients and admit 30 to 40 in a 24-hour period,” says Renee Buhman, RN, the Emergency Department’s educator. Buhman credits specially trained staff and advanced technology for much of the hospital’s success in dealing with cardiac cases. “With a high volume of patients in general, there is always the potential for

a higher number of acute care patients like those presenting with chest pain or other cardiac complaints. When we can determine whether the patient does or does not have an acute cardiac event, the appropriate diagnosis can be made. Siemens point-of-care cardiac technology gets us this information fast.”

The Role of Cardiac Marker Testing “In an emergency setting, speed is critical for patients who have electrocardiographic signs of a heart attack, referred to as ST-elevation myocardial infarction, or STEMI. These patients require immediate attention,” Berkowitz says. “They are very sick people, and we take them directly to the catherization lab for inva-

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Cardiac Emergency Care

cal marker testing, which requires that blood be drawn and evaluated for chemical indicators that show whether a heart attack has occurred. These typically include a troponin test, which may be ordered along with other cardiac biomarkers, such as CK-MB, which in high concentrations indicates long-term damage of the heart muscle, or myoglobin. “Elevated troponin is a good indicator of heart attack, because when heart cells die, they release troponin into the bloodstream,” explains Berkowitz.

Summary Challenge: • Reduce amount of time for cardiac biomarker test results for quicker diagnosis of patients with atypical MI symptoms • Improve management of chest pain patients in the emergency department • Implement protocol that results in proven efficiency to allow better reimbursement under pay-forperformance system Solution: • Initiate point-of-care biomarker testing using the Stratus CS Acute Care Diagnostic System from Siemens Healthcare Diagnostics right in the ED • Establish a protocol for the use of the systems that allows for best patient care and clinical workflow • Educate physicians, nurses, and laboratory personnel about the benefits of point-of-care testing Result1: • Dramatic time savings on test results (troponin and other cardiac biomarker test results available in only 14 to 17 minutes) • Earlier diagnoses lead to earlier intervention (70 percent reduction in time from ’door to PCI‘) • 56 percent reduction in admissions for low-risk chest pain patients • Faster turnover of ED beds, reduction of unnecessary procedures, lowered length of stay, and fewer readmissions of cardiac patients • Better patient care • Organized, efficient use of clinicians’ time and hospital’s resources • Improved reimbursement 1

Results may vary. Data on file.

Quickened Response “In the past, it was necessary to send blood specimens to the lab for testing,” adds Buhman. “We would get results back in 30 to 45 minutes minimum.” Now, St. David’s South Austin Hospital has turned that number upside down, typically getting results in only 14 to 17 minutes. The reason? Three years ago, the hospital implemented four Stratus CS Acute Care Diagnostic Systems from Siemens right in the Emergency Department to run the blood assay tests, saving precious time for patients. With its high sensitivity2 troponin test method, proximity at the point of emergency patient care, and quick test turnaround times, the Stratus CS systems’ protocol translated into meaningful results for patients. Cardiac biochemical marker results are delivered in mere minutes, not the standard onehour ’vein to brain‘ timeframe recommended by many international medical organizations. “With reduced time to decision, we are able to initiate therapies much more quickly. Those extra minutes of time can be the difference of life or death for a patient with heart disease,” says Berkowitz. Further, getting results faster provides some relief on an emotional level, explains Buhman. Chest pain patients frequently are anxious, she says. “If we find their cardiac biomarkers are indicating an acute cardiac condition, we can let the patient know quickly and

“With reduced time to decision, we are able to initiate therapies much more quickly.” Steve Berkowitz, MD, Chief Medical Officer, South Austin Hospital, St. David’s HealthCare, Austin, TX, USA

sive treatment as quickly as possible. It’s almost like Monopoly – do not pass Go; do not collect 200 Dollars; go right to the cath lab.” According to the Chief Medical Officer, the situation becomes trickier when people do not have ’typical‘ symptoms – severe, crushing chest pain “like an elephant standing on your chest,” pain radiating down the arm, severe shortness of breath, nausea, vomiting, and sweating. “As many as half of patients don’t have the typical textbook symptoms,” he reports. “And time is just as critical for those people as it is for those who have an established heart attack on the electrocardiogram.” In these non-STEMI (NSTEMI) cases, standard protocols call for cardiac biochemi-

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2

Defined by the ESC/ACC/AHA/WHF committee as an imprecision level of ≤10 percent at the 99th percentile of normal.

Cardiac Emergency Care

Integrated Technology: Helping Transform U.S. Healthcare Today, hospitals in the U.S. are facing immense pressure to provide more efficient and higher quality healthcare while reducing costs. Increasingly, reimbursement is linked directly to a hospital’s clinical performance. Sandra Sieck, RN, President of Sieck Healthcare Consulting in Mobile, Alabama, a top expert on healthcare business reform, has worked with more than 2,000 hospitals across the country to optimize clinical and financial outcomes. According to Sieck, though U.S. per capita spending on healthcare substantially outpaces European countries, the U.S. fails to achieve better health outcomes, and has been shown in multiple studies to be last on dimensions of access, patient safety, efficiency, and equity. Patients and payers alike are demanding fundamental, widespread change. Advanced integrated technology is helping lead the way.

American versus European Models Per capita spending in the U.S. is higher than in Europe, largely because of differences in disease prevalence. The U.S. takes a more aggressive approach to detecting and treating patients, yet data shows that Americans are in poorer health, with higher rates of serious chronic illnesses.

Reimbursement Challenges The U.S. multipayer system also presents financial challenges, explains Sieck. “With its multiple rules, forms, and procedures, it costs an estimated 20 to 30 percent of the total healthcare expenditure, in contrast to only ten percent in Canada and some European countries,” she says. “Today, in the U.S., we’re seeing increasing expenditures and expanding federal benefits to cover a growing beneficiary population, Baby Boomers and Baby Loomers [babies born in the 70s]. As a self-funded government payer, CMS [Centers for Medicare and Medicaid Services], the federal agency that operates the Medicare program, has only two

begin treatment. When biomarkers and the ECG are negative, we can let those patients know their condition does not show an acute cardiac condition at that time. We decrease patient anxiety by letting them know if they have an acute cardiac event going on or not. Information gives patients back the control they feel has been lost.”

choices: raise taxes to cover waste or eliminate waste, such as excessive treatment times, unnecessary resource utilization, and unnecessary hospitalizations.” As a result, CMS is seeking widespread transformation of the U.S. healthcare system and is using reimbursement as a major impetus for change. In 2007, the Secretary of Health and Human Services delivered a report to Congress suggesting ways to transform Medicare from a passive payer to an active purchaser of high-quality, efficient healthcare. That plan includes value-based purchasing, which links payment more directly to the quality of care and rewards providers who supply it.

The Future of U.S. Healthcare Value-based purchasing demands that identified patient populations receive specific medical and clinical tests and treatment in accordance with professionally recognized standards of healthcare to assure full CMS market basket reimbursement. Hospitals must have: • Better asset or resource utilization – omit waste • Optimized decision times – fast, accurate test results that facilitate timely treatment decisions • Shorter lengths of stay – reduce stays, but not being so lean that hospitals face compliance issues or negative patient outcomes • Fewer admissions for unnecessary chest pain rule-out There is no easy answer for improved clinical and financial success, but advanced, integrated technology is a key component to providing more efficient and higher-quality healthcare. Combination testing using advanced technology, such as the integration of laboratory, IT, and imaging, help ensure better data for treatment decisions and improves cost-effectiveness through improved clinical workflow. Patients and hospitals alike benefit from better quality and maximized efficiency; hospitals can increase reimbursement.

St. David’s South Austin Hospital and a second hospital in the St. David’s system are the only facilities in Austin using the Stratus CS systems to deliver rapid results for the diagnosis of a cardiac event in NSTEMI patients. From 2003 to 2007, the number of NSTEMI patients in the Emergency Department increased by 68 percent. Yet, the hospital has seen a 70 per-

cent reduction in time from ’door to PCI‘ (time the patient came through the door to percutaneous coronary intervention). Additionally, the hospital has realized a 56 percent reduction in admissions for low-risk chest pain patients. Besides improving the speed of appropriate patient therapy, Berkowitz and Buhman credit the state-of-the-art tech-

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Cardiac Emergency Care

“We decrease patient anxiety by letting them know if they have an acute cardiac event going on or not.” Renee Buhman, RN, Educator, Emergency Department, South Austin Hospital, St. David’s HealthCare, Austin, TX, USA

nology for helping increase numerous efficiencies in the hospital. These include, for example, faster turnover of Emergency Department beds, reduction of unnecessary procedures, appropriate use of telemetry beds, lowered length of stay, and fewer readmissions of cardiac patients.3 Additionally, the hospital has seen reimbursement improvements, according to Buhman. “There is a better chance of appropriate reimbursement when evidence supporting the physician diagnosis and assigned treatment is in black and white. The elevation in cardiac markers provides just that in ACS/chest pain patients.”

Synchronized Effort “The protocol would have never worked without the buy-in of our chief pathologist, laboratory department, and emergency nurses,” says Berkowitz. “With CLIA [Clinical Laboratory Improvements Amendments] licensing at stake, there were concerns from the lab, which wanted to be sure the tests were performed and analyzed correctly.” He con3

Results may vary. Data on file.

tinues, “Intuitively, we wanted to get the test done as fast as we could, which meant the ED nurses, not laboratory personnel, would be responsible for performing the tests. When the nurses saw how the timeliness would improve patient care, they committed to learning how to perform the tests.” Now, about 60 nurses are trained to use the analyzer, which translates into direct time savings and faster intervention. The Stratus CS Acute Care Diagnostic System is uniquely designed for use in an acute care setting. Small in size, the analyzer can be configured as both a bench-top or stand-alone workstation, with its own lightweight cart, refrigerator, and uninterrupted power supply. This is what St. David’s South Austin Hospital uses. “We had the choice of going with a competitor’s handheld device or the Siemens Stratus CS,” says Berkowitz. “We chose the Stratus CS system based on its speed and high sensitivity testing, but also because of the track record of Siemens and the confidence we have in the company. The analyzers are the same ones the lab has always been using, so they

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knew the instrument and were comfortable with it. Overall, we have been very pleased with the system, plus the training and support by Siemens and their Clinical Quality Initiatives team has been exceptional,” he says. In any busy emergency department, there are moments when time is critical. When cardiac patients arrive, the pressure is on and the clock is ticking. For this central Texas hospital, expedited high-sensitivity4 troponin testing in the Emergency Department with Siemens Stratus CS Acute Care Diagnostic Systems has led to unprecedented results – improving efficiency, buying valuable time, and making a difference to patients. Diana Smith is a freelance writer based in Liberty Hill, TX, USA. 4

Defined by the ESC/ACC/AHA/WHF committee as an imprecision level of ≤10 percent at the 99th percentile of normal.

Further Information www.siemens.com/diagnostics

Cardiac Emergency Care

At South Austin Hospital, cardiac biomarkers like troponin are analyzed with four Stratus CS Acute Care Diagnostic Systems directly at the point of care in the Emergency Department.

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Training and Maintenance

Only a few steps separate the classrooms from the imaging systems.

State-of-the-art Training With UPTIME Services, Siemens Healthcare offers joint trainings for both customers and Siemens Service Engineers worldwide, providing a variety of technical and application courses to keep everyone’s expertise on the cutting edge. By Justus Krüger

Gil Palcone was a little disappointed at first. Siemens Philippines – computed tomography (CT) supplier of The Medical City Hospital in Manila – was not going to send him to Erlangen, Germany for his training course, as it did two months before, but to the new Siemens Training Center in Shanghai. “I did have doubts whether the courses in Shanghai would be as good as in Germany,” says the 43-year-old biomedical engineer. His doubts, however, disap-

peared as soon as he arrived in Shanghai. “I am 100 percent satisfied with the classes here,” Palcone happily declares – and is already hoping for an update of his skills in a specific SOMATOM® Definition AS+ training. The Siemens Training Center in the Chinese metropolis is part of Siemens Healthcare’s global training concept. The training, part of Siemens UPTIME Services, helps customers worldwide maintain their expertise on the cutting

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edge of medical and clinical technology, and develop it even further – regardless whether they take place in Germany, the U.S., or China.

Global Training Concept “Our global training concept helps provide the same high standards in all training facilities,” says Thomas Weller, General Manager for Customer Services at Siemens Shanghai Medical Equipment.

Each Siemens Training Center is equipped with a variety of the company’s systems for hands-on maintenance and repair training.

The courses help Siemens customers deepen their understanding of extremely sophisticated, state-of-the-art medical equipment such as the company’s magnetic resonance imaging (MRI) and CT scanners, or radiography, fluorography, and angiography systems. That in turn empowers them to optimize workflows, avoid and detect operational errors, and fully utilize their equipment’s potential. This improves examination results and increases patient care and satisfaction.

For the healthcare providers, optimizing workflows also means higher system availability and a marked reduction in terms of costs. These are significant issues for the whole spectrum of Siemens Healthcare customers. Equipment such as CT scanners is in such high demand, especially in large hospitals, that patients often have to endure a long wait. With an inhouse engineer educated in one of Siemens Training Centers smoothing out poten-

tial failures within the framework of a Shared Services agreement, the systems can be utilized more efficiently, saving time for both operators and patients.

Theory and Practice “That is an important factor,” says Weller, “especially when it comes to systems such as CT scanners, which are often in use non-stop from eight in the morning to ten in the evening.” Indeed, far from merely providing the latest theoretical

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Training and Maintenance

The Siemens Training and Development Center in Cary (left) opened in 1992. In 2006, Siemens built a new Training Center in Erlangen.

Worldwide Training A leader in medical technology, Siemens Healthcare has implemented a global training process in order to offer state-of-the-art training for Siemens Customer Service Engineers (CSEs) and customers worldwide. Three Training Centers have been set up in: Erlangen in southern Germany; Cary in North Carolina, U.S.; and Shanghai in China. All Training Centers are equipped with the latest Siemens systems and the most current software. The Training and Development Center in Cary opened in 1992, featuring a 70,000-square-foot training facility with fully functional computed tomography (CT), magnetic resonance imaging, and X-ray systems and 35 classrooms. In 2006, the Erlangen Training Center opened after Siemens Healthcare invested approximately €20 million in the building and close to €40 million in its equipment. More than 50 imaging systems, which include 15 systems in angiography, two SOMATOM® Definition, several Biograph™ and MAGNETOM® systems, as well as syngo® Suite are available to participants. The center in Shanghai is the most recent addition. As part of Siemens Medical Park Shanghai, it is equipped with state-of-the-art technology, which includes three types of CT scanners: SOMATOM Spirit, Emotion, and Sensation, two digital radiography and fluoroscopy systems (AXIOM® Aristos and Iconos), as well as several multimodality workstations to conduct syngo software and Oncology

training, the Training Centers also offer practical application, which is truly indispensable to provide first-class medical service. The training divides participants into four levels, depending on their

network and workstation training. “Many clinics would be happy to have the newest systems and the most current software installed as we do,” says Volker Froede, who is responsible for Siemens Healthcare’s Training Centers. However, participants can also train on older systems and even on ones that are no longer sold. Each Training Center is highly independent yet also interconnected with its two sister centers. If a customer or CSE requires training not offered in Shanghai, Siemens provides a possibility for him or her to join a class in either Erlangen or Cary, wherever the needed training is offered. Siemens has designed most training courses for both customers and Siemens personnel in order to provide the same high level of education to internal staff and customers. A strong emphasis is placed on certification. All Siemens participants must take a test and receive a certificate after having passed it. Many application training courses also offer the CME (Continuing Medical Education) credits that medical doctors require. In addition to classroom training, Siemens offers, for example, virtual training, web-based classes and onsite training. More than 14,000 participants worldwide attend about 1,400 training sessions at the Siemens Training Centers every year. In addition, about 16,000 people make use of e-learning, thereby making a difference to millions of medical professionals, patients, and their families all around the world.

knowledge level: Basic, Advanced, Expert, and Refreshment. The target groups for trainings include physicians, radiology technologists and radiographers, as well as engineers and hospital IT administra-

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tors. Siemens not only offers its customers the chance to continuously enhance their skills, but is also sending their own service engineers back to school: The main participants, other than customers

Training and Maintenance

of Siemens Healthcare, are Siemens Customer Service Engineers (CSEs). Combining the courses for customers and Siemens staff, UPTIME Services provides a great opportunity to exchange valuable experience. As providing good quality training is a top priority of Siemens, the number of participants per course does not exceed twelve. This allows an intensive exchange between trainers and participants. It also helps provide everybody with plenty of opportunity to work with the systems and to get hands-on experience with the equipment. For Palcone, this is one of the big benefits of the training concept. “We don’t only study theory; we apply it to the systems – every day,” he says. “That way you can really absorb the knowledge.” Driven by an innovative concept, the courses offer an interactive training method that is more like a workshop or a seminar than a lecture. Trainers keep checking whether everybody is following; participants ask back; the discussions are lively. That way, the trainers have a clear picture of how far each student has progressed at any one time and how much catching up there is to do. Also, it is simply more fun and contributes to a good learning atmosphere.

High-Quality Training All three training centers offer the same quality of training, and that is, in part, due to the same level of skills and knowledge demanded from the trainers. No matter if they work in Shanghai, Cary, or Erlangen, the requirements are high, not only in technical knowledge, but also in the ability to teach and transmit that knowledge. All prospective trainers first take courses along with Siemens customers in one of the three Training Centers before they start teaching individual modules. After that, they will receive ’Train the Trainer’ education and finally can start to teach whole courses under the supervision of an experienced instructor. Upon receiving a certification and having several months of experience, supervisors will observe their teaching in the classes again. “That way, we can make sure that we really

get the quality we want,” Weller says. This, however, is not the end of quality control. “We ask participants – via a questionnaire or online – how valuable the training was for them,” says Volker Froede, who is responsible for the global

Siemens International Medical Park Shanghai Probably no other Chinese city, or even Asian metropolis, has risen higher in excitement than Shanghai. More than merely capitalizing on its romantic past, Shanghai is a vibrant city that promises plenty for the future. In this forward-looking metropolis, Siemens has invested more than €30 million to set up a new landmark facility. In May 2007, Siemens Healthcare China’s headquarters and Siemens Shanghai Medical Equipment moved together to the Shanghai International Medical Zone (SIMZ) as a pioneer in this new development area. SIMZ is an ambitious project of the Shanghai municipal government covering 11.5 square kilometers in Shanghai’s southeastern Nanhui district. The new zone, set to be completed in 2015, is projected to be an international center of medical care, education, training and research and development (R&D). The move thus also marked the successful integration of Siemens Healthcare China’s R&D, manufacturing, service, sales, and marketing resources with more than 1,000 Siemens Healthcare employees, working closely together under one roof. Together with Siemens Healthcare’s first comprehensive medical equipment show center in Asia and Siemens Healthcare’s Service Center for Asia, the new facility represents a strong center of gravity for Siemens Healthcare’s activities in China and Asia.

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Small courses allow an intensive exchange between trainers and participants, and help provide everybody with plenty of opportunity to work with the

training strategy. “A high percentage of the questions have to come back with either ‘excellent’ or ‘good’, otherwise we have to initiate changes to the training.” To help provide a truly global and standardized training approach, trainers

rotate worldwide. An instructor from Shanghai can be asked to teach in the U.S. and Germany, while a U.S. trainer is just as fit to teach in Erlangen or in Shanghai as in Cary. All courses are held in English, as the centers not only serve

“I am 100 percent satisfied with the classes here.” Gil Palcone, Biomedical Engineer, The Medical City Hospital, Manila, Philippines

The Medical City Hospital in Manila, Philippines, a private, tertiary care hospital, serves some 40,000 inpatients and 380,000 outpatients a year.

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their respective home markets. The center in Shanghai, for instance, is attracting interest not only from China but serves the entire Asia-Pacific region. In a typical week, Manish Pathak, a trainer and Senior Manager at Siemens Healthcare, will be teaching a class of ten students who may come from six countries within different corners of Asia-Pacific, from Russia to Japan or from China to Australia.

Growing Fast China was a logical choice as the location for the third Siemens Training Center. “China is a fast growing healthcare market, and on its way to be the largest market in Asia,” says Weller. “That means there is a high demand for technical experts and knowledge [in China]. The close interaction of R&D [research and development], manufacturing, and customer service makes a lot of sense. It achieves a host of synergy,” explains Weller. It is, in fact, the synergy that develops between education and service that further helps to better diagnose and correct any issues that may arise. A basic course in CT, for instance, enables operators to benefit from Siemens service support even more than usual. While today, based on the service agreement, many system malfunctions can be solved remotely via Siemens Remote Service (SRS), some system malfunctions require onsite support by a trained

systems and get hands-on experience with the equipment.

engineer, for example, with regard to the exchange of a spare part. If inhouse engineers at the customer’s site have been trained by Siemens in certain issues within the scope of a Shared Services agreement, a good understanding of the system allows them to talk the technical language of the Siemens expert, identify and explain the issue via telephone, and initiate relevant tests. “That really enables the customer to have a meaningful discussion with the expert in the Siemens Service Center. If this is not the case, the Service Center would usually send a Siemens Customer Service Engineer to the hospital,” says Pathak. In contrast, when an inhouse engineer or operator has a good knowledge of the system, he or she can leapfrog several time-consuming steps in the procedure. In case a problem can be identified inhouse or with the help of the Service Center, Siemens can immediately send an engineer along with the required spare part. “If you have a good preliminary diagnosis, you can save a lot of time,” Pathak adds.

the temperature in a CT scanner’s cooling system leaves a range of tolerance, the scanner will automatically report to the Service Center. Then, a Siemens engineer can proactively contact the institution where the system is located and either solve the issue remotely or dispatch a Customer Service Engineer to go to the customer’s site. If the inhouse engineer in the hospital or clinic has a good grasp of the system, he can count on his knowledge to work together efficiently with the Siemens expert. “I think the combination of remote service and training is really ideal,” Weller says. Palcone agrees. “We have an excellent working relationship with Siemens,” says the engineer from Manila. Last month, Palcone says, there were difficulties with the hospital’s MRI system. Thanks to his experience, his course, and Siemens Remote Service, the problem got fixed within 15 minutes. “Good for Siemens,” Palcone laughs. “But even better for us. This is really a win-win situation.”

Summary

Justus Krüger is correspondent for the Berliner Zeitung in Beijing, China.

Result: • Competitive edge thanks to higher efficiency • Higher system availability because of workflow and maintenance improvements • Improved examination results through utilizing all existing functionalities • Faster, more secure diagnoses • Increased patient satisfaction

Training and Siemens Remote Service The combination of training can truly increase efficiency. SRS links the equipment at the health service provider with a Siemens Service Center, enabling experts to recognize sources of error in many cases even before the customer becomes aware of them. For instance, if

Further Information www.siemens.com/ medical_training_center www.siemens.com/ uptime-services

Challenge: • Utilize the full potential of medical equipment • Keep expertise on the cutting edge • Optimize workflows Solution: • Global training process to offer state-of-the-art training • Three main Training Centers in Erlangen, Germany; Cary, U.S.; and Shanghai, China • Variety of technical and application trainings • Innovative training concept combining theoretical and practical training • CME (Continuing Medical Education) credits for various courses • Constant quality controls to meet high standards of excellence • Training Centers equipped with the latest Siemens systems and software • Highly qualified trainers

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Essay Series: Healthcare Systems – Japan

The Japanese Healthcare System By Seiritsu Ogura Professor of Economics at Hosei University in Tokyo, Japan, and Editor of the Japanese Journal of Health Economics and Policy

Japanese healthcare is in a crisis. Unlike past crises, this one is a very quiet one, as it is coming from disappearing essential services. On weekends, we find emergency rooms (ER) of any major hospitals practically deserted, as patients are turned down before – and after – their arrivals. The hospitals don’t have enough staff to operate the ERs, and, even if they did, they couldn’t afford to take care of the patient volume. In rural communities, local governments are closing their public hospitals in large numbers due to lack of funds. We have serious shortages of physicians, nurses, emergency facilities, pediatric hospitals, obstetric facilities, etc. We have observed a series of bad decisions by the Ministry of Health, Labor and Welfare (MHLW) during the past decade that should have contributed to this crisis, but they are more results than causes. We have a shortage of funds because we have not infused enough money into our health insurance system to care for the growing population of the elderly. In the past few years, no one wanted to talk about tax increases for fear of losing the next election. The government has been piling up a huge national debt for almost two decades, which has reached almost twice the size of the GDP. The implicit debt in our public pension program is almost the same size too. The Ministry of Finance wants to restore primary balance by year 2011 and wants the MHLW to keep the lid on healthcare expenditures, allowing only a ¥1.1 trillion increase in the costs of all social security programs during the five-year period prior to 2011. In response to these pressures, MHLW produced a reform package in 2006 con66 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

Essay Series: Healthcare Systems – Japan

“The root cause of our present crisis is the shortage of funds.” sisting of medical insurance programs for people over 75, and a new reinsurance scheme for people from 65 to 74. They put them into effect in April 2008, but so far, they have turned out to be extremely unpopular. In what follows, I will explain the outlines of this financial reform package and the reasons why it has met with strong public opposition. For historical reasons, the Japanese public health insurance system consists of two basic types of insurance programs: employees’ programs and municipal programs. The two types of programs have very different comparative health risks and financial bases. In short, employee programs have smaller healthcare needs and a larger revenue base, while municipal programs have much larger healthcare needs and a smaller revenue base. In spite of these gaps, up to the 1970s, the government was able to provide sufficient subsidies for the municipal programs to keep them running. As retired workers started to concentrate in the municipal programs, however, these gaps started to widen even further. By the early 1980s, the government, facing its own huge deficits, could no longer keep up with paying subsidies to meet the bulging demands of the municipal programs. In 1982, the government introduced reinsurance of the healthcare costs of those at age 70 or older in our health insurance. In the scheme, the government contributed half of the costs, and asked all the programs to pay for the other half, according to a formula using several factors, including the number of individuals in their programs. Over the

Seiritsu Ogura Professor of Economics, Hosei University, Tokyo, Japan, and Editor of the Japanese Journal of Health Economics and Policy

years, the contribution formulas have been modified several times, and in the meantime, the minimum age for reinsurance has been moved up to age 75. Finally, starting in April 2008, the government renamed the reinsurance scheme as ’medical insurance programs for the old-old,’ reorganized it into regional insurance programs, and started to collect ten percent of the costs mostly through their own poll taxes. Furthermore, it has come up with its own benefit package, adopting comprehensive payment for most outpatient care, instead of the former fee-for-service system. This scheme has generated an enormous public outcry. Some have even compared the insurance to a legendary ‘granny dumping mountain,’ blaming the government for attempting to deny anyone above the age of 75 their normal healthcare services. As soon as the details of this package became public, most physicians expressed their strong opposition to its comprehensive payment scheme, claiming that it will prevent them from performing necessary procedures, using necessary drugs, and ordering necessary tests. Furthermore, because of the regressive poll taxes, this old-old insurance has been very unpopular, particularly among

the poor. It may very well cost the present ruling parties the next election. In the past, there was another reinsurance program involving those under the age 75, in which employee programs reimbursed municipal programs for the cost of those who had switched from employee pensions. Starting in April 2008, the government replaced this program with a comprehensive reinsurance of healthcare costs of all the individuals between the ages of 65 and 74. Their healthcare costs are paid by all insurance programs in proportion to the shares in insured individuals between birth and age 74. The government makes no independent contribution to this scheme, but it provides subsidies to municipal programs for half of their contributions and to small companies’ programs for 17 percent of their contributions. This new scheme has met another strong protest, this time from large companies. Let me explain why. Suppose we have someone who had his 65th birthday on the 31st of December last year. Let us also suppose that he used to spend one unit of healthcare a year until his 65th birthday, but now he spends four units a year. We want to find out how the extra three units will be paid in our new re-

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Essay Series: Healthcare Systems – Japan

Facts & Figures An Aging Population: Japan has the highest life expectancy, the lowest infant mortality, and the most aged population in the world today. It will age even further in the first half of this century. By the year 2055, life expectancy for men is expected to reach 83.7 years, compared with 79.2 years in 2007, while women’s life expectancy is expected to reach 90.3 years, compared with 86 years in 2007. Reflecting the improved longevity and low fertility, the percentage of the population at age 65 or older increased dramatically, from 4.9 percent in 1955 to 20.1 percent in 2005. It is expected to reach 40.5 percent in 2055.1 Medical Care System: Japan has a national health insurance system. The insurance covers the entire population either through employee programs, municipal programs, or special programs. All programs offer the same benefits. Employers pay 50 percent of the insurance premium. Patients currently contribute either 10 percent (age 70 or older) or 30 percent (all others and affluent elderly) to the cost of inpatient or outpatient care, or prescription drugs. Children also have a 20 percent co-payment, but many municipalities and cities are now bearing some or all of these costs to attract and keep citizens. For people between age 70 and 74, the co-payment rate was scheduled to move up to 20 percent, but the move is temporarily suspended. There is a maximum subsidy of ¥350,000 (about US$3,200) to the cost of delivery for childbirth. Routine checks during pregnancy are not covered by health insurance. Within the Organization for Economic Co-operation and Development (OECD) countries, Japan ranks slightly below the average in terms of health spending per capita, but the contribution of its public sector to health spending is – at 83 percent – well above the OECD average of 73 percent. Japan has fewer physicians per capita, about two thirds of the OECD average, which is at least partly due to government policies fixing limits on the number of new entrants to medical schools. Japan has the highest number of hospital beds, more than twice the OECD average, and the highest number of magnetic resonance scanners, about four times the OECD level. Long-term Care System: Public long-term care insurance was introduced in the year 2000 to provide various home care and institutional care services for the elderly. Insurance premiums are collected in two ways: namely, through a surcharge to health insurance taxes for individuals between age 40 and 64, and through community poll taxes for residents age 65 or older. The co-payment for benefits is set at ten percent of the costs. The total cost of the benefits has already doubled since the start of the system and reached ¥5,571 billion in 2006.2 Half of the costs are paid by general tax revenues. Morbidity and Mortality: Circulatory system diseases are the most prevalent major diseases among the elderly, affecting 30.1 percent of this population segment. They accounted for ¥5,379 billion, or 21.5 percent of the medical expenditures, in 2005. Cancer was the leading cause of death, accounting for 30.1 percent of all deaths, followed by heart disease for 16 percent, and by cerebrovascular diseases for 12.3 percent.3 Lifestyle Risk Factors: Smoking is by far the most important single health risk factor in Japan. Smoking among Japanese men is, with 39.9 percent, still the fourth-highest among developed countries, whereas cigarette prices are at one of the lowest levels. An average pack cost ¥304.6 in 2007.4 There are few smoke-free public areas.5 Recently, the government has been emphasizing obesity as a major health risk. Although only 3.9 percent of all Japanese in 2005 were obese (compared to 34.3 percent in the U.S. in 2006), it has launched a compulsory national program to check for metabolic syndromes for employees at age 40 or older.

1 2 3 4 5

2008 Annual Report on the Aging Society, Cabinet Office, Government of Japan www.mhlw.go.jp. Last accessed Sept. 16th, 2008 www.mhlw.go.jp. Last accessed Sept. 16th, 2008 www.mof.go.jp. Last accessed Sept. 16th, 2008 www.who.org. Last accessed Sept. 16th, 2008

68 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

Women: 85.99 years (2007) Men: 79.19 years (2007)

Dentists Number per 1,000 Resident Population 0.761 (2006)

Hospital Beds Number per 1,000 Resident Population 8.2 (2006)

Physicians Number per 1,000 Resident Population 2.1 (2006)

Nurses Number per 1,000 Resident Population 9.3 (2006) Life Expectancy at Birth

Population in Thousands:127,678 (March 2008)

Total Expenditure on Healthcare as Percentage of GDP: 8.2% (2005)

Share of the Age Group 65+ of the Health Expenditure: 35% (2005)

Contribution of the Public Sector to Health Funding:

82.7% (2005)

Total Expenditure on Healthcare per Capita (adjusted for purchasing power parity): US$2,474 (2005)

Essay Series: Healthcare Systems – Japan

“We have a shortage of funds because we have not infused enough money into our health insurance system to care for the growing population of the elderly.” Seiritsu Ogura Professor of Economics, Hosei University, Tokyo, Japan, and Editor of the Japanese Journal of Health Economics and Policy

insurance scheme. First we must consider co-payment, then this reinsurance, and lastly, government subsidies. By a simple back-of-the-envelope calculation, we find out that co-payment pays only three percent, government pays 25 percent, premiums of employee programs pay 52 percent, and premiums of municipal programs pay less than 20 percent. In 2005, the insurance premiums paid 49 percent, and the government paid 36 percent, of national healthcare costs. The new reinsurance package will increase the marginal share of premiums to 72 percent and reduce the marginal share of the government to 25 percent. The government is simply shifting its burden to employee programs. Employees are already paying almost the same amount as their own healthcare

Seiritsu Ogura is a Professor of Economics at Hosei University in Tokyo, Japan. He is also the Editor of the Japanese Journal of Health Economics and Policy, the official journal of the Japan Health Economic Association, and a member of its Board of Directors. He is a graduate of the Department of Law, Tokyo University, and earned a PhD in Economics from the University of Pennsylvania. He was a Chief Economist at the Japan Cen-

costs in their payments for the elderly. As the elderly population increases, so will the employees’ payments. This process will eventually stop when a sufficient number of those in employee programs get angry. I would hate to see more rounds of cuts in our healthcare services and their tragic consequences. Besides, we should worry about the deadweight losses from such very high payroll tax rates: They will reduce employment and the companies’ profit. Payroll taxes may be far better than poll taxes, but they are not as equitable as consumption taxes to finance the healthcare of the growing elderly population. After the next election, I hope politicians will summon enough courage to raise the consumption tax rate to solve our current crisis in healthcare. Another interesting implication of this reform package is its impact on weaker company-specific employees programs. We still have more than 1,200 companyspecific programs, many of which may decide to dissolve and join the new regional programs for employees of small companies, rather than paying higher tax rates. In the long run, we may come closer to having more integrated health insurance programs, at least among the employees’ programs.

The opinions expressed in this article do not necessarily reflect those of Siemens Healthcare.

ter for Economic Research, one of the leading think-tanks in Japan, before he joined Hosei University. Since the 1990s, he has been working in the field of aging issues and public health in Japan, including population projections, public pension reforms, public health insurance reforms, and, most recently, long-term care insurance reforms and tobacco control issues. He has co-edited two books, Aging Issues in the United States and Japan (2001) and Labor Markets and Firm Benefit Policies in Japan and the United States (2003), both published by the University of Chicago Press.

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Further Reading

Further Reading Siemens offers a variety of customer magazines and information channels. ’Further Reading’ introduces a selection of articles and topics featured there that may be of interest to you. To learn more, follow the link below each article. To subscribe to any of the magazines, see page 77.

Artis zeego delivers precise images during the intervention and can easily be stowed away when not needed.

Artis zeego Supports Hybrid Rooms The combination of a C-arm with robotic technology is the formula for Artis zeego®, the latest high-end angiography system from Siemens. Artis zeego provides the physician with almost unlimited freedom of movement. The system’s flat detector rotates around the patient at such high velocity and precision that cross-sectional soft tissue images are created, acquiring more anatomical details than ever before possible with an angiography system and thus, increasing diagnostic certainty. Artis zeego allows the physician to adapt the working height to his or her individual needs, reducing fatigue and back pain during long procedures. If the system is not used, it can be conveniently parked

out of the way, which is particularly useful in hybrid operating rooms (OR), which combine radiology, cardiology, and surgery. The Interventional Center at the Rikshospitalet in Oslo, Norway, was the first facility to implement Artis zeego in such a room. “When we plan an operation in the limited space of an OR, the increased flexibility with Artis zeego means that we don’t have to restrict ourselves to avoid problems with the C-arm,” says Per Kristian Hol, MD, Manager of Radiological Research. “Instead, we can make the plan with a full focus on the patient and the best procedure for the operation at hand.” Increasingly advanced and complicated

interventions performed in the hybrid room require the full support of a C-arm, especially for changes during the procedure or immediate control. As Hol confirms, “When expertise and technology are scattered, you always are at risk of losing precious time if something needs to be adjusted. Artis zeego decreases that risk.” That is, Artis zeego enhances patient outcomes as it enables imaging and treatment with greater speed, efficiency, and precision.

www.siemens.com/AXIOMInnovations-zeego

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Further Reading

T2

FLAIR

DWI 67-year-old male patient with dysphasia and right-side hemiparesis

Paradigm Shift in Echocardiography The acquisition of nonstitched, real-time, fullvolume 3D images of the heart in one single heart cycle with the new ACUSON SC2000™ volume ultrasound system marks a breakthrough in echocardiography. Called ’Echo in a Heartbeat,’ the technology represents a paradigm shift in ultrasound imaging, 55 years after the world’s first cardiac ultrasound recording using Siemens technology in 1953. With a high-volume acquisition rate – in one second, every second – acquisition time is dramatically reduced, improving workflow in the echocardiography suite. The advanced architecture of the ACUSON SC2000 system delivers vastly more information than today’s conventional systems and is strengthened by Siemens patented Coherent Volume Formation™ technology. Coupled with the system’s high-volume acquisition rate, Coherent Volume Formation moves away from serial line-by-line acquisition towards simultaneous, multiple beams, delivering excellent image resolution. Customizable, programmable, and protocol-driven workflow sequences deliver repeatability for better outcomes: greater efficiency, accuracy, consistency, and care – from data acquisition to diagnosis. Whitepapers on the advanced system technology and architecture have been published and can be downloaded from the website listed below.

The ACUSON SC2000 volume imaging ultrasound system represents revolutionary innovation for echocardiography.

www.siemens.com/echoinaheartbeat

SWI

ASL

cePWI

Arterial Spin Labeled Perfusion MRI In the neurology world, perfusion refers to the delivery of oxygen and nutrients to tissues by means of blood flow, and is one of the most fundamental physiological parameters. Disorders of perfusion also account for most of the leading causes of medical disability and mortality. Perfusion measurements serve as biomarkers for a broad range of physiological and pathophysiological functions and are of direct diagnostic value in vascular disorders. In the field of magnetic resonance imaging (MRI), perfusion imaging measures the rate at which blood is delivered to tissue. There are several methods for the measurement of classical tissue perfusion. One such method is arterial spin labeling (ASL). ASL MRI is a noninvasive method to assess cerebral perfusion. This technique uses magnetically labelled blood as an endogenous contrast agent. With ASL MR imaging, the protons of arterial water are magnetically labeled in the feeding vasculature of the brain. The labeled arterial protons flow through the vascular tree and exchange water with the unlabeled brain tissue. A perfusion-weighted image can be generated by the subtraction of an image in which inflowing arterial spins have been labeled from an image in which spin labeling has not been performed. Clinical applications include cerebrovascular disease, degenerative disease, brain tumor evalutation, BOLD fMRI, and intervention planning. In clinical neuroscience, while the application of ASL perfusion MRI to the diagnosis and management of acute stroke is both obvious and feasible, the clinical utility of ASL is likely to be much broader since only a minority of acute stroke patients undergo MRI. ASL perfusion MRI could greatly enhance the evaluation of both Transient Ischemic Attack (TIA) and chronic cerebrovascular disease by quantifying regional cerebral blood flow (CBF) in specific vascular territories where interventions may be planned, or by allowing the effects of pharmacological therapies on CBF to be evaluated. Several approaches now also exist for selective arterial labeling, allowing the perfusion distribution of specific arteries to be assessed independently. More detailed information about the applications of ASL are highlighted in the latest neurology edition of the Siemens MR magazine MAGNETOM Flash and can be viewed using the link below. www.siemens.com/ MAGNETOM-Flash-ASL

72 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

Further Reading

A New Vision of Healthcare

Siemens plans to achieve the next generation in optimized care through integrating clinical laboratory diagnostics, medical imaging, and information technology.

In its fall 2008 issue, the Siemens research and innovation magazine Pictures of the Future dedicated a whole section on the early detection of diseases and how Siemens plans to achieve the next generation in optimized care through integrating clinical laboratory diagnostics, medical imaging, and information technology. The articles, complemented with statistics and background information, literally paint a picture of the future – and of the technologies in the Siemens Healthcare development pipeline that may help make it come true.

From Molecules to Man This article describes how, from genes and proteins to cells, tissues, and our entire organism, scientists are in the process of piecing together a systems view of how we work. As they do so, they are linking the results of laboratory tests to diagnostic images, injecting the resulting knowledge into advanced decisionsupport systems, and devising strategies for early detection and targeted treatments.

The Future of Medical Imaging At the center of this article are infraredbased systems that pinpoint abnormal tissues and cells, blood tests that detect traces of cancer proteins, research that is zeroing in on imaging the first signs of Alzheimer’s, and strategies for accelerat-

ing the process of discovering new drugs. An interview with John V. Frangioni, MD, PhD, Associate Professor of Medicine and of Radiology at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts, U.S., focuses on solving clinical problems through the application of advanced engineering and chemistry. Another Harvard expert, Mukesh G. Harisinghani, MD, Director of the Clinical Discovery Program at the Center for Molecular Imaging Research and Director of Body MRI, Massachusetts General Hospital, and Associate Professor of Radiology at Harvard Medical School, explains how magnetic nanoparticles can help in detecting lymph node metastases.

be able to predict whether a patient with breast cancer can be successfully treated without chemotherapy. Automated analysis of tumor-specific genes is the key to a new world of individuallytailored treatment.

Answers in the Blood Accurately diagnosing illnesses such as cancer can be an extremely complex and protracted process. Yet, there are now many tests that provide a fast and accurate identification of diseases in the lab – often using just a few drops of blood. This article explains how some of them work. A second article from the world of laboratory diagnostics focuses on efficiency: In order to accelerate workflows in the clinical laboratory, Siemens has developed an automated laboratory system that runs a large variety of tests in one analyzer. It can analyze up to 200 samples and perform up to 1,500 diagnostic tests per hour.

The Battle Against Breast Cancer This story features major advances in imaging technologies that are now making possible more precise examinations that place less stress on patients, like digital mammography (brought to the patient with the help of mobile units), computed-aided detection, breast tomosynthesis1, automated breast volume scanning2 and eSie Touch elasticity imaging with ultrasound, and magnetic resonance imaging techniques for the breast. Also focusing on breast cancer is an article about how researchers are closing in on a diagnostic test that will

Caution: Investigational Device. Limited by U.S. Federal Law to investigational use. The information about Digital Breast Tomosynthesis is preliminary. This product is under development and not commercially available in the U.S., and its future availability cannot be assured. 2 The information about this product is being provided for planning purposes. The product is pending 510(k) review, and is not yet commercially available in the U.S. 1

www.siemens.com/PoF

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Further Reading

How to Reduce Dose Outstanding developments in the field of computed tomography (CT) within the last ten years – for instance Dual Source CT (DSCT) or dual energy – have increasingly made it a standard examination method for many indications. Thus, the question of radiation dose becomes more and more important. The German Heart Center in Munich, in cooperation with the American Mayo Clinics in Rochester and Jacksonville, and the Friedrich-Alexander University in Erlangen-Nuremberg, Germany, conducted the ‘International Prospective Multicenter Study on Radiation Dose Estimates of Cardiac CT Angiography in Daily Practice (PROTECTION-I).’ The study compared five CT units from four different manufacturers. It included 1,965 cardiac CT scans that were carried out in a total of 50 clinics and heart centers. The results show clear differences in radiation doses depending both upon the CT system manufacturer and the behavior

of the operator. Radiation can be significantly reduced by more consistently using already existing technologies for dose reduction in CT systems, for example, the 100 kilovolt scan protocol or the step-and-shoot mode. According to the study, the SOMATOM® Sensation 64 performed best. Close behind was the DSCT SOMATOM Definition. Thomas Flohr, PhD, head developer of the SOMATOM Definition Dual Source at Siemens Healthcare in Forchheim, Germany, believes that “The DSCT would have performed even better if it had already been equipped with the current, improved version of the step-and-shoot technology during the study.” Despite this, in identical clinical situations in the study, the average radiation dose of the DSCT SOMATOM Definition was more than ten millisievert below that of the competing scanners ranked in fourth and fifth place. Clearly, Siemens has developed a radiation-saving system and

49-year-old patient with a high-grade lesion in the right coronary artery revealed by a quick, 1.8 mSv, low-dose cardiac examination with the SOMATOM Definition with Adaptive Cardio Sequence.

additionally provides very good systems training so that operators can take advantage of the total radiation reduction potential of the device.

www.siemens.com/ SOMATOM-Sessions-Dose

Diagnostic Center Frankfurt: Innovation and Expertise at the Highest Levels By Wiebke Kathmann, PhD

A visually impressive new building, modern work processes, extremely upto-date equipment, and outstanding cooperation between the Departments of Radiology and Cardiology are the cornerstones of success at the new Diagnostic Center of the University Hospital in Frankfurt am Main. The architecture is intriguing: clean lines, spaciousness, and a waiting area that looks like a VIP lounge. Heading up the Diagnostic Center and adding to its appeal by creating an aura of tranquility are the Director of the Diagnostic and Interventional Radiology Department, Professor Thomas Vogl, MD, and cardiologist and Director of the Medical Clinic III, Professor Andreas Zeiher, MD. Patients feel well cared for – also, of course, due to the fact that both Vogl and Zeiher are renowned experts in their fields and offer innovative interventions. Vogl’s international forte

is computed tomography-(CT) and magnetic resonance imaging-(MRI) guided intervention mainly of liver and lung tumors and metastasis. People from all over the world consult him for transpulmonal percutaneous chemoembolization, a method used for localized chemotherapy of lung tumors, or for laser-induced interstitial thermotherapy (LITT). Zeiher’s specialty, among others, is regenerative medicine, for example, stem cell therapy, specialized catheter interventions, and measurement of intracardiac flow in diastolic dysfunction. The appropriate environment for these manifold capacities was established with the new Diagnostic Center. In order to cope with the changes in the German healthcare system, an update of facilities and concentration of resources was necessary, as the center’s Commercial Director Dr. Hans-Joachim Conrad,

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stresses. Now, all functional aspects – from the helicopter landing place on top of the building, to the Departments of Radiology and Cardiology in the middle, to the shock room in the basement – are located in one building. “We were able to tighten our processes and increase efficiency – among other things – through the bundling of the latest imaging systems in one building,” says Conrad. The center is equipped with state-of-the-art equipment from Siemens: three MRI systems, eight angiography systems, three CT scanners, and one urology system support expertise in Frankfurt, providing patients with innovative care.

www.siemens.com/ news-frankfurt

Service

Feedback Dear Reader, The Editorial Team of Medical Solutions was honored with distinguished awards from respected corporate publishing and communications organizations. At the Best of Corporate Publishing Congress in Munich, Germany, Medical Solutions received two exceptional awards, placing it among the top corporate magazines in Europe. It won a Silver Award in the area of ‘B2B – Industry, Technology, Energy, and Pharmaceuticals,’ where Medical Solutions was the only healthcare magazine honored. It also obtained a second Silver Award in the category of ‘International Communication,’ a new category that included over 180 entries. The jury was comprised of more than 100 renowned experts from

journalism, design, marketing, corporate communication, print, and direct marketing. With more than 600 entries, the contest is the largest of its kind in Europe. At the 14th Annual Communicator Awards, a U.S.-based international awards

Feedback to the editor should be addressed to: by mail:

Siemens AG, Healthcare Sector CC CB1 Doris Pischitz Chief Editor Medical Solutions 91050 Erlangen Germany by e-mail: editor.medicalsolutions. [email protected] by fax: +49 9131 84-4411 Please include postal address, email address, and phone number. Siemens reserves the right to edit readers’ comments for clarity, length, or compliance with legal/regulatory requirements.

program that honors creative excellence for communications professionals, the magazine received an Award of Excellence in the area of ‘Corporate Magazines.’ Entries were scored on a ten-point scale by judges from the International Academy of the Visual Arts, in which Excellence Winners receive a 9.0 or above. We are very proud of these achievements and thank our interview partners and contributors for their continuous input and support. We hope you appreciate Medical Solutions as much – or even more – as the juries, and are looking forward to hearing from you soon! Sincerely,

Doris Pischitz, Chief Editor

Trade Fairs & Congresses Title

Location

Short Description

Date

Contact

MR 2009

Garmisch-, Partenkirchen, Germany

13th International MRI Symposium

Jan. 20 – 24, 2009

www.mr2009.org

Arab Health 2009

Dubai, United Arab Emirates

International Healthcare Exhibition and Congress

Jan. 26 – 29, 2009

www.arabhealthonline.com

Molecular Summit

Philadelphia, PA, USA

Integration of Imaging and Diagnostics

Feb. 10 – 12, 2009

www.molecular-summit.com

ECR 2009

Vienna, Austria

Annual Meeting of the European Society of Radiology

Mar. 6 – 10, 2009

www.ecr.org

EAU Annual Congress

Stockholm, Sweden

24th Scientific Congress of the European Society of Urology

Mar. 17 – 21, 2009

www.eaustockholm2009.org

ACC 2009

Orlando, FL, USA

Annual Scientific Session of the American College of Cardiology

Mar. 29 – 31, 2009

www.acc.org

HIMSS 2009 Chicago, IL, USA

Annual Conference and Exhibition Apr. 4 – 8, 2009 of the Healthcare Information and Management Systems Society

www.himssconference.org

75th JT DGK Mannheim, Germany Annual Conference of the German Society for Cardiology

Apr. 16 – 18, 2009

www.ft2008.dgk.org

conhIT

Apr. 21 – 23, 2009

www.conhit.de

Berlin, Germany

Information Technology in Healthcare

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Imprint

© 2008 by Siemens AG, Berlin and Munich, All Rights Reserved

Publisher: Siemens AG

Healthcare Sector Henkestrasse 127, D-91052 Erlangen, Germany Responsible for Contents: Dr. Stephan Feldhaus Director of Customer Communications: Silke Schumann Chief Editor: Doris Pischitz Editorial Team: Sonja Fischer, Katja Stöcker, Abigail Weldon Production: Norbert Moser All at: Henkestrasse 127, D-91052 Erlangen, Germany Phone: +49 9131 84-7529, Fax: +49 9131 84-4411 email: [email protected] Design and Editorial Consulting: independent Medien-Design, München, Germany in cooperation with Primafila AG, Zürich, Switzerland Art Direction: Horst Moser Layout: Lucie Schmid Editorial Coordination: Christa Löberbauer Photo Editor: Susanne Nips All at: Widenmayerstrasse 16, D-80538 München, Germany PrePress: Reinhold Weigert, Typographie und mehr... Schornbaumstrasse 7, D-91052 Erlangen, Germany Printer: Farbendruck Hofmann, Gewerbestrasse 5, D-90579 Langenzenn, Germany

Photo Credits: Cover: Justin Jin Cover Story: Erin Trieb, Justin Jin, Imke Lass, haraldhoffmann.com, Getty Images Essay Series: Portrait Noma Bar, Charts Martin Stallmann Patient-centered Medicine: Jez Coulson Magnetic Resonance Imaging: Douglas Harrison Engle/WPN Radiation Therapy: Imke Lass Facility Planning: Jez Coulson, Alberta Heart Institute Integrated Healthcare: WixPix Productions, Inc. Ultrasound: Abbie Trayler-Smith Cardiac Emergency Care: Jez Coulson Training and Maintenance: Ryan Pyle/WPN Note in accordance with § 33 Para.1 of the German Federal Data Protection Law: Dispatch is made using an address file which is maintained with the aid of an automated data processing system. We remind our readers that when printed, X-ray films never disclose all the information content of the original. Artifacts in CT, MR, ultrasound, and DSA images are recognizable by their typical features and are generally distinguishable from existing pathology. As referenced below, healthcare practitioners are expected to utilize their own learning, training, and expertise in evaluating images. Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data, such as author’s name and title of the contribution as well as date and pages of Medical Solutions, are named. The editors request that two copies be sent to their attention. The consent of the authors and editors is required for the complete reprint of an article. Manuscripts submitted without prior agreement as well as suggestions, proposals, and information are always welcome; they will be carefully assessed and submitted to the editorial conference for attention. Medical Solutions on the Internet: www.siemens.com/healthcare-magazine

DISCLAIMERS: Practice of Medicine: “The information presented in this magazine is for illustration only and is not intended

to be relied upon by the reader for instruction as to the practice of medicine. Any healthcare practitioner reading this information is reminded that they must use their own learning, training, and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Healthcare to be used for any purpose in that regard.“ Contrast Agents: “The drugs and doses mentioned herein are consistent with the approved labeling for uses and/or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating your Siemens system. The source for the technical data is the corresponding data sheets.” Trademarks: “All trademarks mentioned in this document are property of their respective owners.“

76 Medical Solutions · December 2008 · www.siemens.com/healthcare-magazine

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Medical Solutions Innovation and trends in healthcare. The magazine is designed especially for members of the hospital management, administration personnel, and heads of medical departments.

AXIOM Innovations Everything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semiannual magazine is primarily designed for physicians, physicists, researchers, and medical technical personnel.

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On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States.

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The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases.

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Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

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