Evaluating the present and future diagnostic/imaging technological trends

Diagnostic/imaging systems are valuable tools for the chiropractic profession, as they represent an investment not only in one’s practice but in the patients treated. However, chiropractors must understand the ins and outs of such devices to optimize their adaptability. Chiropractic Products invited four specialists to offer advice on the mechanics and future waves of diagnostic/imaging systems.

Jim Combest is director of marketing for Myotronics-Noromed Inc, Tukwila, Wash. He has more than 20 years of experience in the development and marketing of diagnostic equipment for the health care industry.

Suzi Plank is vice president of corporate services for Practice Perfect, Long Beach, Calif. During the past 15 years, Plank has provided technical and management services to health care providers, specializing in radiology and neurology.

Steve Keller is vice president of sales for Scrip Chiropractic Supply Inc, Peoria, Ill. He has worked with Scrip in the chiropractic supply industry for more than 20 years.

Frederick R. Fischer is vice president of AllPro Imaging Inc, Hicksville, NY, and has been the senior executive since the company was established in 1985.

What diagnostic/imaging systems or equipment do you recommend for chiropractic offices? Why?
Combest: Your choice of diagnostic systems should be determined by your needs: Are you looking for a patient education tool? An effective, reliable, and authoritative method of objectively documenting function? A tool that provides objective clinical data necessary for a proper diagnosis? Or a combination of all three? Choose your diagnostic instrumentation based on the components of the VSC: kinesiopathology, myopathology, neuropathology, histopathology, and biochemical abnormalities. From a kinesiological standpoint, dynamic range of motion (ROM) allows you to measure, document, and evaluate the patient’s patterns of movement in addition to objective measurement of ROM according to the American Medical Association (AMA) Guidelines.

For the myopathic and neuropathic portions of diagnostic testing, there are computerized manual muscle testing and surface electromyography (SEMG). Computerized muscle testing can help establish nerve root impingement/involvement and will also document muscle weakness. Static SEMG can help you locate and document areas of hypertonicity while dynamic SEMG can help monitor muscle recruitment patterns. These tests, by itself or in combination, are great patient education tools. They also provide an objective, clinical data necessary for a proper diagnosis, as well as providing the objective documentation required for establishing medical necessity of treatment, efficacy of treatment, and eventually, document maximum medical improvement.

Plank: Chiropractic offices should have a basic x-ray system or access to a facility that provides quality radiographs of the regions and views necessary for chiropractors to adequately assess the patient, provide a comprehensive report of findings, as well as obtain digitized spinal and biomechanical analysis reports.

Fischer: The most widely used diagnostic/imaging system in the chiropractic office is the x-ray machine. X-rays are a valuable tool for visualizing subluxation of the spine. The question is not whether to use radiographs, but should x-rays be taken using film or digital systems? Film-based systems have the advantage of lower initial cost. However, the cost of operation can be high when all factors are considered including, for example, the cost of film, chemistry, chemical disposal, film storage, processor repair and maintenance, and even the darkroom itself. Digital systems employ a reusable film substitute. X-rays are taken in the normal manner using the doctor’s existing x-ray equipment. The radiation dose may even be able to be lowered. The digital system reads the image from the film substitute and is stored and displayed using a computer. The x-ray can be read in one minute, which is faster than a film and processor system. Furthermore, there are no continuing supply or maintenance costs. Unlike a static film image, digital imaging allows the chiropractor to use computer enhancement to bring out all of the diagnostic information in the radiograph.

What are some of the costs DCs can expect? Are there leasing or financing options available?
Combest: Costs can vary greatly. To be most cost effective, look for a modular system, one that you can customize but has the flexibility to grow as your needs change. Typically, there are three choices when you are buying diagnostic equipment: leasing, financing, and outright purchase. Because situations are unique, check with your accountant for the most suitable choice.

Plank: Tremendous advances are being made in x-ray systems with digital leading the way. However, the new digital systems are expensive and generally represent an unnecessary additional expense for a doctor in an existing facility with a functioning x-ray unit. The doctor, along with his or her practice consultant, financial advisor, and/or leasing specialist, should carefully review the cost benefit analysis when planning equipment replacements with particular emphasis on how it will impact the bottom line.

Keller: Besides the obvious equipment costs, there are other costs related to setting up an x-ray room and keeping it running properly. Contractor build-out costs, as well as electrical and plumbing costs, are most likely going to be the responsibility of the doctor. In the case of a new office, these can possibly be negotiated into the rent with the landlord. Nuclear physicists’ reports and lead are also additional costs.

Fischer: [Our product] is sold through authorized dealers, most of whom offer leasing and financing plans. And, don’t forget that in 2004, the IRS allows full depreciation over 1 year of qualifying capital equipment up to a total of $100,000.

What legal issues should DCs know about?
Combest: Before you purchase a diagnostic instrument of any type, make sure that it complies with US Food and Drug Administration (FDA) requirements. Some states require state-approved training for DCs and some require training for staff performing the tests. It is best to check with your state association for specific requirements.

Plank: Liability. Most chiropractors, although trained in analysis of plain films, are not board certified in radiology. When properly taken, x-rays can gather an astonishing amount of necessary information about the patient. Pathology that is not recognized or noted is a liability issue. One way chiropractors can reduce their liability is by using a service, at no cost to them, to digitize their x-rays and have mensuration lines applied, which also includes interpretation of the films by a board certified radiologist.

Keller: Each state has their own set of laws for lead shielding requirements. The state FDA office is the governing body for those requirements. Other possible restrictions include the size of the lead window used in the operator barrier, the size of the barrier, and the square footage needed for the operator to work. Other possible issues include the Environmental Protection Agency (EPA) requirements for disposing used chemicals. These requirements can vary from city to city.

What are the insurance reimbursement issues for chiropractic offices? Are there any preauthorization concerns?
Combest: Diagnostic tests are something that the insurance companies understand. Insurance companies are accustomed to the medical model: 80% diagnostics and 20% treatment. The DC model is the opposite: 20% diagnostics and 80% treatment. To protect your patients and practice, create an evidence-based practice. Use your diagnostic tools to document what you are doing, why you are doing it, and to document progress. Many insurance companies use a computer to review claims. The computer bases its decisions on two criteria: Is it an accepted or unaccepted test and is it subjective or objective? Your opinion may not be believed; it may be perceived as too subjective. However, a computerized accepted diagnostic test with automatically generated reports falls within the insurance industry’s paradigm. Most manufacturers will be able to tell you which codes to bill their tests under. Be aware of outrageous claims. Get a complete copy of the codes they recommend. You should expect a manufacturer to be able to document their information and to be conservative. Do not rely on anecdotal information.

Plank: All health care providers today are faced with downward pressure on their reimbursement and ever increasing preauthorization requirements. Chiropractors must now have the ability professionally and clerically to provide clear, concise documentation of treatment and medical necessity to obtain the authorizations that are required and to justify their billing for services rendered. It is absolutely crucial that chiropractors correlate their findings to the reports from digital analysis of x-rays and any other diagnostic procedures performed. You can go broke on the phrase “I never had to do that before.”

What are some ways DCs use diagnostic equipment for patient education, referrals, and compliance?
Combest: Your diagnostic test should print out a complete, colorful, and understandable report. Spend a minute with the patient to review the report, let them know what you are looking for and how you use this information to track their progress. As an educational tool, the report should include colorful graphics, the option of including the information obtained from the current examination with the results obtained from prior examinations, your name, the clinic name, and address and phone number. By documenting improvement over time you give the patient the motivation to improve visitation compliance. Also, let them take a copy of the report home. A copy of their diagnostic report will be a constant reminder to follow your treatment plan. It can also be a powerful source of referrals for family and friends.

Plank: A patient’s x-ray images, when printed onto photographic paper with mensuration lines and statistical analysis graphs displayed next to normal spine images, illustrates their biomechanical differences as well as structural improprieties. This gives patients information that will motivate them to continue treatment and comply with further recommendations. In addition, the potential for lawsuits is lowered because patients have been well informed with documented references and research data about the necessity of their treatment protocols.

Keller: Show patients their progress by using diagnostic equipment before, during, and at the end of a treatment. When they can feel and see the difference, they will be motivated to correctly comply with the doctor’s instructions and tell others about the great care and results they are receiving.

Fischer: Patients respond more enthusiastically to digital images than to film. Also, features like colorization allow the layperson to truly view x-rays rather than trying to distinguish subtle shades of gray.

What should chiropractors expect from their diagnostic companies?
Combest: Expect a diagnostic company to provide an 800 number for customer service. Also, expect a company to provide regular software updates for their products. Regular updates should reflect changes in the relevant medical guidelines and also indicate that the company is backing its products with ongoing research into its customer’s needs. A good equipment warranty policy is also a must.

Plank: Communication, responsiveness, education, and expertise are applicable no matter what company or type of diagnostic procedure is offered.

Keller: Chiropractors should expect top quality products and service from all of their vendors, not just their diagnostic company. Each doctor deserves quality products delivered quickly. If and when there is a problem, they need to be taken care of instantly. An office cannot be expected to take care of its patients correctly without properly functioning diagnostic equipment.

Fischer: At a minimum, they should expect high quality equipment supported by well-trained dealers.

What are the latest or future diagnostics/imaging technological advances?
Combest: Technological advances are being made all the time. ROM diagnostic equipment has advanced beyond the static “pendulum in a box” model into motion sensing inclinometers, which allows for the documentation, diagnosis, and monitoring of patterns of movement and impairment. SEMG equipment, more reliable and reproducible, has expanded beyond simple static monitoring to up to eight channels of dynamic SEMG, which allow for the evaluation of what the patient presents pathologically and provides the DC with what they need to evaluate and diagnose the patient. Most systems have advanced to the point where they will not pick up stray electromagnetic signals from outside sources such as cell phones.

Buy from a reputable manufacturer, one that has been around awhile. Manufacturers that make their product in-house usually have a more knowledgeable customer service help line if you have a question or problem.

Plank: Digital x-ray is in the forefront of imaging equipment. However, the bigger picture for clinics and offices will be the need for them to migrate to integrated computerized billing, practice management, and documentation systems. Insurance companies and governmental payors are already setting time lines requiring electronic submission of all billing. A state-of-the-art digital x-ray system with remote image retrieval, capable of sharing and attaching images to the patients file electronically will not be productive if you are still on a pegboard system. Digital x-ray and imaging equipment and its interface with other information systems has been problematic and difficult to overcome even for large hospital systems.

Keller: Although digital radiography has been around for awhile, it has not been priced so that the average chiropractor can take advantage of it. Lately, the price has been coming down. The trick will be to maintain quality, to offer a price that is affordable, and have a system that will have integrity and not cost an arm and a leg in maintenance. We are not quite there yet, but the time is coming.

Any last words of advice?
Combest: Diagnostics are an investment in your practice and patient care. Know what your needs are and budget is. If your budget is small, look for a manufacturer that has a diagnostic system that you can build on or upgrade. Also, know what you are buying. Get a copy of any product claims in writing. Do your research; some diagnostic systems come complete with a whole new philosophy that may require you to fundamentally change how you practice.

Plank: Make sure you are maximizing your use of the x-ray film images you currently acquire. A service providing digital and biomechanical analysis and board certified radiologist reports would supply professional reports to incorporate in your documentation and correlate your findings while limiting your liability and containing costs.

Keller: Do not settle for less than you deserve. Quality equipment at great prices should not mean less service. You are making decisions on your patient’s health that are dependent upon the diagnostic equipment you are using. Demand the best. Work with a company that is there for you so that you can be there for your patients.

Fischer: Our world is undergoing a digital revolution. Patients are positively impressed by doctors who use up-to-date technology and equipment. We can either embrace or oppose change. I believe that those who embrace digital technology will benefit both in long term cost savings and in an increased patient base. CP

Marissa Heflin is associate editor of Chiropractic Products.