The future of radiotherapy: Efficiency and accessibility p.

80

Your Industry Source for Healthcare and Equipment Coverage

September 2019

Raising
the
profile of
radiation
oncology
Q&A with
ASTRO president
Dr. Theodore DeWeese
p. 36

Also in this issue

LOOKING TOWARD A FUTURE WITH
FLASH THERAPY
• Researchers discuss what the cutting edge
technique could mean for the future of
cancer care. p. 26

WHAT'S NEW IN PROTON THERAPY

AND RADIOTHERAPY?
• We look around the industry at the latest
technology entering the market. p. 44

DOSE OPTIMIZATION
• When it comes to administering CT
scans, how do you ensure a quality
diagnostic image without excess radiation
exposure? p. 52
RADIATION SHIELDING
• Shielding may not be on your mind every
day, but when it's time for a shielding
project you can't afford to make mistakes.
p. 70
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 CONTENTS
September 2019

FEATURES EXCLUSIVE Q&As

26 20
Looking toward a future with flash therapy Art Gianelli
Researchers discuss what the cutting edge technique could President
mean for the future of cancer care. Mount Sinai St. Luke’s
Delivering healthcare in a 'Lean' framework.
30
Addressing gender disparities in the field of radiation
oncology
When it comes to salary and career opportunities, there are 34
substantial unexplained gaps between male and female Dr. Parag Parikh
radiation oncologists. Director of MR-Guided
Radiation Therapy and
44 director of GI Radiation Oncology
What’s new in proton therapy and radiotherapy? Henry Ford Cancer Institute
We look around the industry at the latest technology Discussing the value of MR-guided
entering the market. radiotherapy.

52 36
Dose optimization Dr. Theodore DeWeese
An update on finding the balance between quality President
diagnostic imaging and radiation exposure. ASTRO
Raising the profile of radiation oncology.
56
Spectral CT
Value, use cases and implementation insights from
Dr. Nakul Gupta. 60
John Boone
62 Professor of radiology and biomedical
AI comes to the CT market engineering, and chief of
Surveying the latest hardware and software enhancing the medical physics
capabilities of CT providers. University of California Davis
Ultrahigh-res scanning comes to CT.
70
Radiation Shielding
Shielding may not be on your mind every day, but when it's time
for a shielding project, you can't afford to make mistakes.

Visit DOTmed.com/news for breaking

news daily, to comment on stories in this
issue, to participate in surveys and more.

HealthCare Business News I september 2019 3



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70 CONTRIBUTING WRITERS

Lisa Chamoff
James D’Arezzo
Lauren Dubinsky
Thomas Dworetzky
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69 Ten-year study finds low-dose CT is the standard for lung
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80 Future of radiotherapy
 Dr. Deepak “Dee” Khuntia, senior vice president and chief
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 Letter from the Editor

Our online news is getting a makeover

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matters most, but that doesn’t mean good
packaging doesn’t deserve a little recogni-
tion. After all, book design is complex stuff
— aside from an enticing cover you’ve got
to select the type size and style of the text, margins to consider, page
size and paper, and on and on.
Anyone with experience in marketing will tell you that the way
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Business News readers will have a more enjoyable and more intuitive
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Gus Iversen
Editor in Chief
giversen@dotmed.com
Twitter: @dotmedcom

Knitting raises thousands for Scottish MR scanner

fundraising campaign
Posted online July 08, 2019 by Lisa Chamoff

A fundraising campaign to help pur-
chase a new MR scanner for Scotland’s
remote Shetland Islands has gotten a
boost from one of the region’s oldest
traditions — knitting.
A year ago, the Shetland Health Board
Endowment Fund began a campaign which
aims to raise nearly £1.65 million to purchase a
scanner for the archipelago, which consists of
16 islands inhabited by roughly 23,000 people.
Currently, about 600 patients a year must
travel via plane, or up to 14 hours over often
rough seas on an overnight ferry, to either
Aberdeen or Glasgow on the Scottish main-
land to have an elective outpatient MR scan.
Enter Harriet Middleton, a knitter who
had to travel to Aberdeen for follow-up MR
scans every three months after having a can-
cerous polyp removed from her colon.
Middleton, who says she has immersed
herself in her beloved hobby “through good
times and bad,” began selling her hand-knit
items at craft shows to raise money for the
campaign. She then started receiving dona-
tions of yarn from local companies, such as
Jamieson’s of Shetland, forming a knitting
group to create more items for the fundraiser.
Middleton designed a pattern for a hat
using the blue and orange colors from the
campaign’s logo. Her son, Billy Middleton,
set up a website and social media accounts
to sell and promote the pattern.
Since the beginning of May, thousands
of online sales of the Harriet’s Hat pattern,
along with sales of Shetland wool yarn
from Lerwick retailer Jamieson & Smith and
knitwear from Middleton and her knitting
group, called MRI Maakers, has raised nearly
£25,000, close to 10 percent of the total
raised so far, toward the target.
“I was overwhelmed and still am over
the response to the campaign,” Middleton
told HCB News. “It shows the power of the
internet. I never thought when I decided to
do something to help raise money for the
appeal that my small effort would generate
so much interest.” 
Share this story: dotmed.com/news/47816

6 HealthCare Business News I september 2019 www.dotmed.com/news

 HealthCare Business Daily News Online
Did you know this magazine is just the
tip of the iceberg? Healthcare industry
current events impact your facility and
they happen when you least expect it.
That's why we cover them every day in
our 100% FREE Daily News online.
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HealthCare Business News I september 2019 7
 Daily News Online > dotmed.com/news

Some medical devices exempted from China tariffs

Posted online July 15, 2019 by Thomas Dworetzky

Last week, the Trump administration
announced it would exempt 110 Chi-
nese products, including some medical
equipment, from its 25 percent tariffs
placed on $34 billion of Chinese imports
on July 6, 2018.
The exclusions are retroactive to that
date, according to Reuters, and will be in
place for a year from last Tuesday.
The U.S. has levied tariffs on $250 billion
of imports from China and now threatens
to tax another $300 billion, as the two na-
tions continue going back and forth with
one another.
There were 12 exclusion requests grant-
ed to Medtronic, including one for a com-
ponent in a device used to treat liver tumors.
Varian Medical Systems also received an
exclusion for some of its equipment after
claiming that that the tariffs would only hurt
their firm, as there are no other “good alter-
natives,” noted Reuters, and that it would
hurt it against European competitors.
Other device components that have been
exempted include “veterinary ultrasound
devices, certain parts and accessories of elec-
tro-surgical instruments, and dental X-ray
alignment and positioning apparatuses,” ac-
cording to a report in Medtech Dive.
But according to a June statement to
USTR by the Advanced Medical Technology
(AdvaMed) Association, which represents
over 400 medical device makers, many
devices that the group hoped would be
exempted, including pacemakers, remain
subject to the 25 percent tariff.
“If tit-for-tat retaliation continues, the
administration’s objectives for a strong do-
mestic medical technology industry will be
undermined. We ask the administration to
consider this adverse impact and to remove
all medical technology products from its re-
taliation lists,” it stated.
In addition, it urged that, “including med-
ical technology products on the USTR list is
troubling from a public health perspective.
Healthcare products have been consistent-
ly recognized as being exempt from trade
sanctions — even with countries which the
United States considers to be security risks.”
An ongoing trade war could threaten the
30 percent market share U.S. makers enjoy
in China, AdvaMed noted. 
Share this story: dotmed.com/news/47897

NNSA awards agreements to CT and MR waiting times

US firms for Mo-99 production costing Canadians over $3
Posted online July 30, 2019 by John R. Fischer billion
Three companies have finalized negotiations for awards with Posted online July 05, 2019 by John R. Fischer
the Department of Energy’s National Nuclear Security Admin-
A new report commissioned by the Conference Board of
istration (DOE/NNSA) for the production of molybdenum-99
Canada, “The Value of Radiology, Part II” specifies that wait
(Mo-99) — using no highly-enriched uranium (HEU).
times for CT and MR diagnostics has cost the Great White
The three companies are Michigan-based Niowave, and Wis-
North $3.54 billion in lost productivity annually, and that an
consin’s NorthStar Medical Radioisotopes and SHINE Medical Tech-
investment of $4.4 billion must be obtained between now
nologies. A possible fourth cooperative agreement with Northwest
and 2040 to modernize its medical imaging equipment.
Medical Isotopes in Oregon is also under negotiation.
“The major challenge in modernizing Canada’s stock of equip-
“Mo-99 is a critical medical isotope that empowers us to fight
ment is that Canada’s CT and MRI machines are old, much older
back against heart disease and cancer,” Lisa E. Gordon-Hagerty, DOE
than the guidelines we use to gauge what’s ideal,” Robyn Gib-
undersecretary for nuclear security and NNSA administrator said in a
bard, economist for the Conference Board of Canada, told HCB
statement. “These agreements will facilitate its domestic production
News. “That means that, in the short term, decision-makers have
without highly-enriched uranium, greatly reducing the potential for
to balance two competing goals: modernizing the stock of equip-
proliferation of nuclear materials.”
ment and reducing wait times.”
Used in more than 40,000 medical procedures daily in the nation,
Approximately 380,000 people each year are forced to tem-
the objective of these deals is to ensure a supply of 3,000 six-day
porarily take leave from work to wait for MR and CT exams longer
curies of Mo-99 per week.
than the recommended maximum wait time. The loss of workers
Congress had appropriated $40 million for the awards for FY
hinders the ability of firms to produce goods and services, which
2018 and $20 million more for FY 2019. The three agreements call
in turn, hurts GDP and reduces government revenues by $430
for NNSA to give $15 million to each of the awardees, which will be
million annually. 
matched by the firms. 
Share this story: dotmed.com/news/47755
Share this story: dotmed.com/news/48086

8 HealthCare Business News I september 2019 www.dotmed.com/news

Consumer experience is top priority for 69 percent
of US hospitals: survey
Posted online July 10, 2019 by John R. Fischer

Improving consumer experience is top periencing improved quality outcomes and lowed by greater patient adherence to care
or second among the priorities of 69 improved patient engagement, while 65 plans, reductions in unnecessary utilization/
percent of healthcare C-suite executives, percent report a higher number of patients readmissions, and improved patient reten-
according to a survey conducted by re- sticking to care plans, and 54 percent seeing tion. While 81 percent of C-suite executives
search firm Sage Growth Partners. improved patient retention. use navigators with clinical backgrounds,
Commissioned by healthcare experience Utilized the most in oncology, orthope- programs of high value rely on non-clinical
and patient navigation enterprise, Docent dics and cardiology, the adoption of patient navigators, which were found to be more
Health, the survey examines strategies imple- navigation programs is mainly stimulated by effective than clinical ones.
mented by hospitals across the country to a desire to improve patient engagement, fol- Share this story: dotmed.com/news/47831
improve such experiences, a task which is
becoming essential due to changes in how
healthcare services are managed and paid
for, says Stephanie Kovalick, chief strategy
officer for Sage Growth Partners.
“Consumers are starting to feel a higher
burden of paying for services themselves,” she The Accurate and Affordable Answer to Home Reading
told HCB News. “Healthcare consumers have LG 27" 8MP Clinical Review Monitor
anywhere from $2500-$10,000, and some-
times even more in deductibles, so they’re
paying for so much care out-of-pocket. As you
start to spend your own money, you’re much
more careful about the choices you make
in how to spend that money. We’re seeing
healthcare consumers a lot more discerning in
where they’re going to receive care and how
they make decisions for follow-up care based
on the experience they had the first time.”
The surveyors spoke to 100 healthcare
C-suite executives from different hospitals
across the country in the first quarter of
2019, with 64 percent from highly com- 27HJ713C-B

petitive markets, 33 percent in moderate

ones, and three percent in noncompetitive
environments. Of the respondents, those in
highly competitive markets were more likely
to view improving consumer experiences as - DICOM out-of-the-box calibrated to ACR-AAPM-SIIM secondary review brightness guidelines
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sider it among their top four priorities.
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More than half, however, use patient
navigation programs, with 67 percent ex-
HealthCare Business News I september 2019 9
 Daily News Online > dotmed.com/news

Micro-X develops own carbon nanotube X-ray tube

Posted online July 23, 2019 by John R. Fischer

Micro-X has manufactured a new car-
bon nanotube X-ray tube for its plat-
form of X-ray products.
Composed of a carbon nanotube elec-
tron emitter, development of the tube will
make Micro-X one of two companies in
the world capable of developing CNT-
based X-ray tubes, alongside third-party
supplier, XinRay, for products such as the
Carestream DRX-Revolution Nano mobile
X-ray system.
“The advances Micro-X has made
in this new X-ray tube design — both in
the quality and potential lifetime of this
innovative new tube — will be of great
benefit to healthcare providers,” Charlie
Hicks, general manager of X-ray solutions
at Carestream Health, said in a statement.
“We at Carestream are the first company
to introduce carbon nanotube X-ray tech-
nology to the medical imaging field, and as
our sales of this new device grow, Micro-X
is well-positioned to quickly supply antici-
pated demand from customers.”
CNT-based X-ray tubes are the first to
not use heated-filament electron emission,
reducing size, weight, heat and power.
Originally relying on XinRay for manufac-
turing, Micro-X set to work developing its
proprietary CNT emitter in 2017 at its base
in Adelaide, Australia, employing a small
team of world-leading experts in engineer-
ing chemistry and nanomaterials science to
work alongside researchers at Flinders Uni-
versity and the University of Adelaide.
The total cost of the project was approxi-
mately $3 million, including for the develop-
ment work and new capital equipment. Part
of this sum was supported by funds from a
$2.4 million matching grant secured under
the Federal Government’s Advanced Manu-
facturing Growth Fund.
The process involved key elements such
as design, process engineering, production
engineering and validation and testing. It
also focused on improving existing reliabil-
ity standards and garnering support from
stakeholders to create a smooth transition
from the current supplier to Micro-X inter-
nally manufactured X-ray tubes.
In developing its own tubes, the compa-
ny expects to achieve increased commercial
margins and enhanced flexibility in future
product designs, including for the Rover and
Mobile Backscatter Imager product that is
being developed with Thales. 
Share this story: dotmed.com/news/47962

New AI solution identifies New study links low dose

high-risk patients from chest radiation to increased
X-rays cancer risk
Posted online July 23, 2019 by John R. Fischer Posted online July 26, 2019 by John R. Fischer

Chest X-rays may hold more information that could identify
patients at high risk for a range of conditions, including heart
disease and lung cancer.
That’s the consensus arrived at by researchers at Massachusetts
General Hospital, who have developed a new AI tool called CXR-risk
to determine which patients would benefit the most from screening
and preventive medication.
“We developed and tested this convolutional neural network
in healthy outpatients. The hope is that it will help primary care
physicians and patients make decisions about prevention, screen-
ing, and lifestyle,” Dr. Michael T. Lu, director of research of MGH
Cardiovascular Imaging, told HCB News. The underlying idea is that
we can use CNNs to extract information about health and longevity
embedded in everyday medical images.”
Trained on analyses of more than 85,000 chest X-rays from
42,000 subjects, the solution is designed to identify combinations
of features on a chest X-ray that best predict health and mortality.
Each image used to train it included information on whether or not
the person died at any point over a 12-year period.  few turn into cancer.
Share this story: dotmed.com/news/48007
Administering low-radiation doses equivalent to that of
three CT scans may boost the number of cancer-capable cells
over normal cells in healthy tissue, according to a new study.
Researchers at the Wellcome Sanger Institute and the University
of Cambridge used mice to show that low doses of radiation in-
crease the number of cells with mutations in p53, a genetic change
associated with cancer. They argue that such a risk should be con-
sidered in radiation safety assessments.
“The reduction in radiation exposure is desirable, and limiting
imaging and using optimized scanning protocols are important
ways forward,” professor Phil Jones of the Wellcome Sanger Insti-
tute and MRC Cancer Unit at the University of Cambridge, and Dr.
David Fernandez-Antoran of the Wellcome Sanger Institute, told
HCB News.
Although information on the impact from exposure to low levels
of radiation is limited, all humans carry cancer-capable mutant cells
in healthy tissue, including those with p53 mutations. Cells with
this mutation increase in number as a person ages, though very
 
Share this story: dotmed.com/news/48049

10 HealthCare Business News I september 2019 www.dotmed.com/news

Radiologists voice workload frustration in research
report released at SIIM
Posted online July 03, 2019 by John W. Mitchell

A survey conducted of a small sample of “[With conversational AI,] I would be Increased patient and reporting work-
radiologists at academic medical centers, able to extract data and put it into more loads have created what the president of
healthcare systems, radiology practices, structured reports,” said Dr. Brian Kaineg, the World Medical Association has called a
and hospitals confirmed a litany of radiol- neuroradiology, Quantum Radiology. “That “pandemic of physician burnout,” according
ogist workflow and practice complaints, would be ideal because then you could set to the report, which is entitled In your words:
such as tedious methods of measure- up a template that everything populates How AI is advancing the impact of radiology
ment, job burnout, and inefficient work- into and the radiologists wouldn’t neces- in healthcare. Porter Research conducted the
flow in the face of increasing workloads. sarily need to change the way they’re rou- survey between January and March of 2019. 
The report, which consisted of interviews tinely dictating.” Share this story: dotmed.com/news/47789
with nine radiologists and their response to
23 questions, was prepared by Porter Re-
search and sponsored by imaging AI solu-
tions company, Nuance Communications.
Nuance released the report at the 2019 SIIM
annual meeting currently convened in Au-
rora, Colorado.
“Radiologists are being pressured by larg-
er and larger workloads, due, in part, to ris-
ing patient volumes and inefficient systems
and processes,” Karen Holzberger, vice presi-
dent and general manager of diagnostics for
Nuance, told HCBN. “The unfortunate result
is that many radiologists are burned out. We
wanted to hear directly from the source on
what can be done to alleviate the stress and
tension, and specifically, what role can in-
novative technology play?”
Dr. Alexander Towbin, a radiologist in the
department of radiology and medical im-
aging at Cincinnati Children’s Hospital, said
radiologists deliver a service in an expensive
environment that needs to be efficient.
“Workflow efficiency is something that
I believe is important,” said Towbin. “We all
know ... medical costs are out of control, and
no one can afford them; so we need to be ...
cognizant of what we spend and what we
ask for our patients.”
Holzberger said that incorporating narrative
reporting into structured data and integrating
intelligence and AI-generated findings directly
into the workflow to automate and augment
reports is a proven solution. The access to AI,
pre-populating data within reports, automat-
ing repetitive or time-consuming routine tasks,
structured reporting formats, and other fea-
tures are recognized as high-value capabilities.
HealthCare Business News I september 2019 11
 Daily News Online > dotmed.com/news

With stock value up 51 percent, is Mindray too pricey?

Posted online July 16, 2019 by Thomas Dworetzky

Shenzhen-based Mindray Bio-Medical
Electronics has soared since going pri-
vate in 2016, and is taking market share
from both GE and Siemens.
And in May it got put into the MSCI
China All Shares Health Care 10/40 Index,
which “captures large and mid-cap repre-
sentation across China A-shares, B-shares,
H-shares, Red-chips, P-chips and foreign list-
ings,” according to MSCI, and which “aims
to reflect the opportunity set of China share
classes listed in Hong Kong, Shanghai, Shen-
zhen and outside of China.”
Its stock has risen 51 percent, making it
“a top performing equity on the ChiNext
board” — and that has given it a $29 billion
valuation, according to Bloomberg.
But some think it may have gone a bit
too far, a little too fast, with a P/E ratio of
39, despite a Bloomberg forecast of a 20
percent revenue growth and 21 percent an-
nual income growth from now to to 2021.
That’s because the consensus price tar-
get for Mindray is 158.90 yuan, showing a
possible 3.8 percent downside from present
stock values.
The company is “looking expensive,” al-
though not too much so versus other China
high-fliers, like soy sauce maker Foshan Hai-
tian Flavouring & Food, Xiong Qi of Windsor
Capital Management told Bloomberg.
The firm had been listed in the U.S. on
the NYSE until being taken by a subsidiary
of Excelsior Union Limited for $1.9 billion
in 2016.
The maker of in-vitro diagnostics equip-
ment, life monitoring systems and medical
imaging equipment, including color ultra-
sound devices, has been liked by institutional
investors, thanks, in part, to its rising R&D
investment, and government support as
China seeks to become a bigger player in
the global market, according to Bloomberg.
At present prices, there are those who
think the values are a bit high and are hold-
ing off. Dai Ming, portfolio manager of
Hengsheng Asset Management Co., told
Bloomberg that, “Mindray’s valuation is too
high. We will wait for a pullback to get in at
a more reasonable price.” 
Share this story: dotmed.com/news/47896

Noritsu acquires R&F New bill calls for changing

Imaging Systems
Posted online July 10, 2019 by John R. Fischer
Noritsu America Corporation has acquired R&F Imaging
Systems, a sales and service company for medical imag-
ing equipment.
The agreement is poised to provide Noritsu with medical im-
aging expertise while expanding the operations of the Atlanta-
based R&F to nationwide scale.
“Because we are a manufacturer, we understand the need
for and use of data collection to help large customers under-
stand trends and anomalies in their capital equipment,” Patrick
Todd, vice president of business innovations at Noritsu, told HCB
News. “Noritsu and R&F can provide a single service agreement
to multi-site caregivers and medical imaging providers so that
the level of service is efficient, consistent, and easy to manage.”
In business since 1984, R&F offers a full line of X-ray sales
and services throughout the greater Atlanta area of Georgia,
and brings to Noritsu experienced medical imaging technicians,
certifications and manufacturer relationships, and industry con-
nections, as well as a desire to expand geographically.
In return, the industrial photographic imaging equipment
provider of 47 years offers R&F a national footprint working with
clientele of all sizes, from independent shops to national chains.
Share this story: dotmed.com/news/47850
reimbursement for
radiopharmaceuticals
Posted online July 24, 2019 by John R. Fischer
A new bill that would ensure adequate Medicare reimburse-
ment for procedures that use radiopharmaceuticals has been
introduced before the U.S. Congress.
Issued by Representatives Scott Peters (CA-D.), Bobby Rush (IL-D.)
and George Holding (NC-R.), the Medicare Diagnostic Radiopharma-
ceutical Payment Equity Act of 2019 is expected, if passed, to extend
patient access to highly-targeted, precision diagnostic procedures for
more accurate diagnoses and treatment of diseases, such as Alzheim-
er’s and Parkinson’s, by changing the way in which reimbursements for
such exams are carried out.
“Current CMS policy only allows for separate payment of diagnostic
radiopharmaceuticals in the hospital setting during the two- to three-
year transitional pass-through period. After the transitional pass-through
period, the payment for the radiopharmaceutical becomes bundled with
many others in the procedure payment,” Terri Wilson, senior director of
patient access and healthcare policy at Blue Earth Diagnostics and cur-
rent chair of the MITA PET Group, told HCB News. “When this happens,
hospitals are significantly underpaid for newer precision diagnostic radio-
pharmaceuticals, and some may stop offering the service, thereby limiting
patient access. HR 3772 would correct this issue.” 
Share this story: dotmed.com/news/47993

12 HealthCare Business News I september 2019 www.dotmed.com/news

Philips Q2 sales helped by Chinese healthcare
spending
Posted online July 23, 2019 by Thomas Dworetzky

Rising healthcare spending by the Chi-
nese government boosted Philips to
above-expectations sales growth in Q2
— with comparable sales up 6 percent
versus a 4.5 percent analyst forecast.
The company saw a “double digit” sales
rise in China, according to Reuters, due in
part to government expansion of hospitals
and purchase of more high-tech healthcare
equipment.
“Healthcare in China is still not sufficient to
meet the demands of an aging society,” Phil-
ips CEO Frans van Houten told Reuters.
“The government has said it would
expand capacity, and that is exactly what
is happening. This trend for us is more im-
portant than fluctuations in GDP growth,
and we expect it to continue in the coming
years,” he explained to the news agency.
Sales rose in the U.S. and Europe as well,
according to the company.
“We saw growth in all our segments in
the second quarter and we expect that to
continue,” Van Houten said, adding that,
“we had strong traction in emerging mar-
kets and that is set to continue. Also, we
expect mature markets to come in stronger
in the second half of the year.”
Despite the positive sales news, the com-
pany advised that ongoing tariff woes will
impact both its components and products.
“The main cloud hanging over us is the
possible fourth batch of tariffs,” Van Houten
stated. “If that would happen, it would in-
crease the amount by which our earnings
are hit by 20 million euros this year, but no-
body knows whether it will happen.”
The company now anticipated that it will
lose about $51 million of earnings in 2019
due to tariff impact.
Despite that, the presently forecast 4
percent to 6 percent total comparable sales
growth through 2020 remains in place, with
a projected profit margin up from 13.1 per-
cent to 14 percent for the year.
Adjusted earnings before interest, taxes
and amortization (EBITA) rose 14 percent to
549 million euros in the second quarter, and
margin grew 11.8 percent, near expecta-
tions, said Reuters. 
Share this story: dotmed.com/news/48024

CMS proposes alternative US leading digital health

payment model for radiation record adoption, but falls be-
oncology hind elsewhere: Philips report
Posted online July 17, 2019 by John R. Fischer Posted online July 24, 2019 by John R. Fischer

The Centers for Medicare and Medicaid Services has pro-
posed an advanced alternative payment model for providers
administering radiation oncology procedures.
Aimed at supporting the transition toward value-based care,
the Radiation Oncology (RO) Model encourages the adoption of
prospective site-neutral, episode-based payments by physician
group practices, hospital outpatient departments, and freestanding
radiation therapy centers for radiotherapy. This model is expected
to reduce Medicare expenditures, while maintaining or enhancing
the quality of care for Medicare beneficiaries.
“The new model provides incentives for high-quality, more
convenient radiation treatments and rewards concordance with
evidence-based clinical guidelines,” Dr. Brian Kavanagh, immedi-
ate past chair of ASTRO, told HCB News. “The model also has the
potential to stabilize reimbursement in the long term and move the
specialty from an antiquated fee-for-service payment structure to
one based on quality and value.”
The prospective episode-based payments would apply to the
treatment of 17 types of different cancers, with providers receiving
payments during a 90-day period of care. CMS expects it to save
$260 million for Medicare in that time.  Share this story: dotmed.com/news/48008
Share this story: dotmed.com/news/47911
The U.S. is among the countries spearheading the adoption
of digital health records globally... In fact, it’s the only digital
technology that the U.S. leads in healthcare, according to
Philips’ U.S. Future Health Index 2019 Report.
The Dutch-based healthcare giant ranks the “Land of Opportu-
nity” below the 15-country average leveraging the full use of digital
healthcare technologies, including telemedicine and AI. And while
used by 84 percent of U.S. healthcare professionals, DHRs still come
with their share of challenges.
“Federal legislation, such as the HITECH Act, helped drive adop-
tion of DHRs over the last ten years and helped U.S. healthcare
move away from disparate, paper-based processes to digital re-
cords,” Dr. Joseph Frassica, head of Philips Research, the Americas,
and chief medical officer at Philips North America, told HCB News.
“Unfortunately, this rush to digitize came without common indus-
try standards for data exchange and normalization, contributing to
data silos and interoperability challenges.”
Lack of standardization hinders interoperability, with 52 percent
of American healthcare professionals less inclined to share health
records among their peers inside their own facilities.
HealthCare Business News I september 2019 13
 Daily News Online > dotmed.com/news

Siemens forms $113 million alliance with UM

System and MU Health Care
Posted online July 17, 2019 by John R. Fischer

Siemens Healthineers has teamed up
with the University of Missouri System
(UM System) and University of Missouri
Health Care (MU Health Care) to estab-
lish the Alliance for Precision Health.
The German-based healthcare giant has
entered into a $133 million 10-year Value
Partnerships agreement with UM System,
which includes all four universities, and
MU Healthcare, in which it will supply both
southern entities with diagnostic and thera-
peutic devices to enhance care delivery, pro-
mote education around technology and en-
gineering, and help create research ventures.
“Our vision for the entire UM System
is to advance the opportunities for success
and well-being in Missouri, the nation and
the world through transformative teaching,
research, innovation, engagement and inclu-
sion,” said UM System President Mun Y. Choi
in a statement. “Forming an alliance with Sie-
mens Healthineers enables us to work toward
this mission by providing our university and
health system with leading-edge technology
and resources, unique research and collab-
oration opportunities, training for the next
generation of the healthcare workforce, and
expansion of our contributions to medicine
and healthcare to rural Missouri and beyond.”
The alliance is expected to help the UM Sys-
tem complete research, educational and clinical
care objectives for its highest priority, NextGen
Precision Health Initiative, a statewide effort
to provide treatments for cancer, Alzheimer’s,
cardiovascular disease and other illnesses that
affect Missourians and people worldwide.
Among the equipment supplied will
be laboratory and imaging technology, in-
cluding the MAGNETOM Terra 7 Tesla MR
scanner, for clinical and research purposes
focused on furthering ultra-high field MR
capabilities. The UM System will also have
access to Siemens’ AI and health digitaliza-
tion tools, such as syngo Virtual Cockpit, a
software solution for connecting radiology
technicians remotely to scanner workplaces
to help personnel in different locations with
sophisticated exams. Enterprise services and
digital solutions will be provided as well, with
Siemens utilizing insights about their prod-
ucts from the UM System and MU Health
Care to improve upon the development of
their medical technologies and services. 
Share this story: dotmed.com/news/47913

Konica Minolta and Shimadzu Agiliti acquires Zetta

bring Dynamic Digital
Radiography to RADspeed
Pro at AHRA
Posted online July 22, 2019 by John R. Fischer
Konica Minolta Healthcare Americas is accelerating the sale
and distribution of its Dynamic Digital Radiography (DDR)
solution for X-ray in the U.S. healthcare market with the help
of long-time partner Shimadzu Medical Systems.
Utilizing Konica Minolta’s new advanced image processing capa-
bilities with Shimadzu’s RADspeed Pro radiographic imaging systems,
the technology provides users with a “movie” that shows the motion
of structures such as bones and lungs. It will make its official debut on
RADspeed Pro this week at the 45th annual AHRA meeting.
“The only way to get the equivalent of a ‘movie’ is with extremely
high dose and varied workflow, which is inconvenient for the radi-
ologist and means a much larger procedure for the patient. Using
the unique Konica Minolta technology and smart X-ray capabilities
for image processing, we can produce at almost the same dose as a
standard X-ray a moving image,” David Widmann, president and CEO
of Konica Minolta Healthcare Americas, told HCB News. “The radiolo-
gist, pulmonologist and orthopedist can actually see the dynamics of
the structure they’re looking at.”  engineers and technicians.
Share this story: dotmed.com/news/47994
Medical Technologies
Posted online July 10, 2019 by John R. Fischer
Healthcare technology management company Agiliti has
acquired Zetta Medical Technologies, a provider of services
and parts for medical imaging equipment.
“Zetta brings to Agiliti a full complement of medical imaging
device management and maintenance capabilities, and decades of
experience across a broad range of equipment makes and models,”
Tom Leonard, CEO of Agiliti, told HCB News. “Their full-service
approach is a perfect fit within our broader clinical engineering
offering to customers — building on our platform of supplemental
and outsourced biomedical repair and maintenance services to
include comprehensive support for high-end medical imaging
technologies (CT, MR and PET/CT), and the scale to deliver those
services nationally.”
The sale opens access for Zetta to Agiliti’s 7,000 healthcare
facility partners across the U.S. through the company’s network of
86 local market service centers and five repair and maintenance
Centers of Excellence. Agiliti also provides a platform for acceler-
ated growth and investment in the form of its 24/7 service model,
nationwide infrastructure and a team of more than 3,000 equip-
ment management experts, which includes over 400 biomedical
 
Share this story: dotmed.com/news/47851

14 HealthCare Business News I september 2019 www.dotmed.com/news

Canon hit with $32 million fine by EU for Toshiba deal
Posted online July 01, 2019 by Thomas Dworetzky

Canon’s extraordinary deal structure
when it picked up Toshiba Medi-
cal Systems Corp. (TMSC) has now
earned it a 28 million euro ($32 mil-
lion) fine from the European Commis-
sion, Bloomberg reports.
At issue was a tactic dubbed “warehous-
ing” that got around filing requirements, EU
antitrust enforcers said in a statement.
“Companies have to respect our com-
petition rules and procedures, said Com-
missioner Margrethe Vestager, in charge of
competition policy, adding that companies
“are obliged to notify and wait for our ap-
proval before a merger can go ahead.”
Of the warehousing he noted, “Canon
structured a transaction to circumvent these
obligations when they acquired TMSC. This
is a procedural breach of our merger review
so we are fining Canon €28 million. Our
merger assessment and decision-making
depends on the Commission being sure that
companies are not jumping the gun and im-
plementing mergers without our approval.”
The EU further broke down the manner
in which Canon’s warehousing broke the
rules.
“For the acquisition, Canon used a so-
called “warehousing” two-step transaction
structure involving an interim buyer.
“As a first step, the interim buyer ac-
quired 95 percent in the share capital of
TMSC for 800 euros, whereas Canon paid
5.28 billion euros for the remaining 5 per-
cent of the shares and share options over the
interim buyer’s stake. This first step was car-
ried out prior to notification to or approval
by the Commission.
“As a second step, following approval
of the merger by the Commission, Canon
exercised its share options, acquiring 100
percent of the shares of TMSC.”
This is far from the first objection incurred
over the deal structure.
Earlier in June, the Canon-Toshiba deal
earned the companies fines of $2.5 million
each to settle U.S. federal charges that they
violated premerger notification and wait-
ing period requirements of the Hart-Scott-
Rodino (HSR) Act with the unusual nature of
the 2016 transaction.
The settlement also requires that the
companies put in place HSR compliance pro-
grams and agree to inspection and reporting
requirements. 
Share this story: dotmed.com/news/47787

Elekta to distribute C-RAD

SIGRT technology in North
America and Mexico
Posted online July 17, 2019 by John R. Fischer

C-RAD has granted Elekta the right to distribute its surface

image-guided radiation therapy (SIGRT) technology to pro-
viders for use in stereotactic radiosurgery, stereotactic body
radiotherapy, and motion management.
Beginning in the North American and Mexican markets, the
agreement brings together the benefits of C-RAD’s Catalyst HD sys-
tem, which integrates with Elekta linacs, and those of Elekta’s Versa
HD high-definition dynamic radiosurgery solution.
“Accuracy is key when escalating dose,” Dee Mathieson, senior
vice president of treatment solutions at Elekta, told HCB News. “The
X-ray products complement the patient set up and motion manage-
ment capabilities of the Versa HD to give confidence to the clinicians.”
A non-surgical treatment, stereotactic radiotherapy is used to
treat functional abnormalities and small tumors within the brain.
Stereotactic body radiotherapy is used to treat the same issues within
the body.
Capable of treating all parts and organs in the body, Versa HD
customizes high-energy X-rays to conform to a tumor’s shape and
destroy cancer cells while sparing surrounding healthy tissue.
The agreement is now in use in the North American and Mexican
markets, with plans to expand. 
Share this story: dotmed.com/news/47910
HealthCare Business News I september 2019 15
 Daily News Online > dotmed.com/news

Global breast ultrasound market expected to reach

$1.7 billion by 2023
Posted online July 11, 2019 by John R. Fischer

The global breast ultrasound market is
projected to reach $1.71 billion by 2023,
according to Global Breast Ultrasound
Market, Forecast to 2023, a report by
research firm Frost & Sullivan.
Valued currently at $1.11 billion, use of
novel techniques by vendors, combined with
machine learning and deep learning algo-
rithms for high-quality imaging and capa-
bilities, such as cloud and data analytics, are
expected to be the main drivers of growth,
along with proactive introduction of applica-
tions and value-based equipment by vendors
based on regional needs.
“Traditional breast ultrasound generally
faces issues in terms of longer examination
times (more than 30 minutes) and sonog-
rapher error, depending on the character-
istic of breast tissues, which necessitates re-
peat scans,” Poornima Srinivasan, industry
analyst, transformational health at Frost &
Sullivan, told HCB News. “In this context,
automated breast ultrasound offers value in
terms of lesser time of less than five minutes
and helps eliminate operator/sonographer
error as the ultrasound probe placement and
movement on the breast are standardized.”
Innovations like miniaturization, nonin-
vasiveness, higher affordability and painless
diagnosis are expected to further boost the
use of ultrasound scanners.
Vendors seeking to benefit from this rise
in the market are advised in the report to
demonstrate evidence-based benefits such
as cost efficiency, improved clinical out-
comes and time efficiency of their solutions,
as well as adopt targeted approaches that
increase procedural volume in breast screen-
ing programs such as ABUS, which takes less
than 20 minutes for scanning.
Additional tasks that help include realign-
ing care models, focusing on automation
and wireless, and expanding new clinical
areas such as optical ultrasound; improv-
ing the value proposition across clinical and
financial stakeholders and providing value
for better managed equipment services,
training, and technical upgrades; and offer-
ing usage-based, service-oriented delivery
models in developing economies.
Srinivasan says that Asia-Pacific countries
such as China and Japan offer opportunities
for ultrasound as a primary diagnostic tool,
and that new business models focused on
operational efficiency and training will help
to increase its use in developed nations.
Share this story: dotmed.com/news/47834

Mayo Clinic Florida campus to Hospital M&A revenue rose

get $233 million proton facility to $11.3 billion in Q2 this year
Posted online July 01, 2019 by Thomas Dworetzky Posted online July 26, 2019 by Lauren Dubinsky

Mayo Clinic is set to build a new $233 million integrated oncolo-
gy facility including proton beam therapy on its Florida campus.
The 140,000-square-foot facility, which will house a two-gantry
proton system, is now scheduled for a late 2023 opening, according
to a Mayo statement.
“This facility will give us the ability to offer our patients the full spec-
trum of cancer treatment options, including chemotherapy, immunother-
apy, CAR-T cell therapy (chimeric antigen receptor therapy T cell therapy),
surgery, proton beam therapy, gamma knife radiosurgery and traditional
radiotherapy,” CEO of Mayo Clinic in Florida, Dr. Kent Thielen stated,
adding that, “it will also give patients access to proton beam therapy
clinical trials offered through our National Cancer Institute-designated
comprehensive cancer center.”
The new facility will be near the Mangurian Building, which offers
hematology and oncology care, and the Oncology Infusion Center, in
order to better integrate cancer care on the campus.
Proton therapy had already been added to the rosters of other
Mayo Clinic campuses in Rochester, Minnesota, in 2015 and Phoenix
in 2016.  critical,” said Singh.
dotmed.com/news/47753
Transacted revenue skyrocketed to $11.3 billion for the
second quarter of this year, almost four times higher than
that generated in the same time last year.
These were the findings of a new Kaufman Hall report on
merger and acquisition activity, and come despite a decline in the
number of hospital and health system mergers and acquisitions
in the same period.
“This trend is simply a response to the changing market,” Anu
Singh, managing director at Kaufman Hall, told HCB News.
The healthcare industry is under a high degree of uncertainty
due to the pressure to take on more risk while continuing to cut
costs. On top of that, organizations may have trouble competing
against new disrupters in the industry, such as Amazon, CVS and
United Healthcare.
“Even larger organizations that have made strides in build-
ing up sites of care and pursuing ambulatory strategies could
also not have the financial or intellectual capital to thrive in a
value-based world where clinical and business intelligence are
 
Share this story: dotmed.com/news/48065

16 HealthCare Business News I september 2019 www.dotmed.com/news

 Upcoming Events
Society for Imaging Informatics in Medicine Leading International Trade Fair
Event: 2019 Conference on Machine Intelligence in Medical
Imaging (C-MIMI) DÜSSELDORF, GERMANY
Location: Hilton Austin Hotel, Austin, TX 18–21 NOVEMBER 2019
Dates: September 22-23
Years in existence: 4 www.medica.de Member of
Average attendance: 250-300
Who should attend: Researchers, Clinicians and students,
Computer scientists, Engineers and Developers represent-
WORLD FORUM FOR MEDICINE
ing technology companies, Startup community working on
innovative solutions.

Annual Radiology Meeting in UAE

MEDICA 2019 –
Event: ARM 2019 Annual Meeting
Location: Dubai International Convention & Exhibition
Centre, UAE

Always
Dates: October 15-17
Years in existence: 4
Average attendance: 1700+

a heartbeat
Who should attend: Radiologists, Radiographers, Hospital
Administrators , Educators & Researchers , Residents & Tech-

2019-05-24 Medica 2019_USA_MEDICA_86 x 224mm_DOTMED_4c_7198

ahead!
nicians, Suppliers, Agents, Distributors, Dealers, Exporters,
Importers, Government Agencies & Radiation Oncologists.

Society of Interventional Radiology

Event: Lower Extremity Arterial Revascularization (LEARN)
Location: Renaissance Nashville Hotel, Nashville, TN
Dates: October 17-19
Average attendance: 100
Who should attend: Interventional radiologists, vascular
medicine physicians, and others with an interest in the clinical
management of lower-extremity peripheral arterial disease.

Society of Interventional Radiology

Event: ACTiVE
Location: The Hilton Scottsdale Resort & Villas, Scottsdale, AZ
Dates: October 24-26
Average attendance: 100
Who should attend: Interventional radiologists and
those who treat VTE. Features a multidisciplinary faculty of
interventional radiologists, vascular surgeons, hematologists,
pulmonologists and cardiologists.

MEDICA 2019
Location: Düsseldorf Fairgrounds, Dusseldorf, Germany
Dates: November 18-21
Years in Existence: 50 For show information: Messe Düsseldorf North America
Tel. (312) 781-5180 _ info@mdna.com
Average attendance: 130,000+ www.mdna.com
Who should attend: GPOs, integrated delivery networks, For hotel and travel arrangements: TTI Travel, Inc.
Tel. (866) 674-3476 _ info@ttitravel.net
HME/DME providers, physician private practice, medical labo-
ratories, HER/EMS/PHR/PACS/RIS, medical services providers.
HealthCare Business News I september 2019 17
 Hospital Spotlight: Mount Sinai St. Luke’s

Mount Sinai St. Luke’s

Location: New York, NY
Year founded: October 18, 1846
(cornerstone laid in 1854,
opened to patients in 1858)
Number of beds: 495
Number of employees: 3200 (approx.)
President: Arthur A. Gianelli

Noteworthy distinctions:
First hospital in New York State to offer TECAB
1
(totally endoscopic coronary artery bypass sur-
gery), performed using micro-incisions. It offers a
quicker recovery time, decreases pain, and lessens 2
the risk of infection.
Verified as a Level II Trauma Center by the Veri-
fication Review Committee, part of the Commit-
tee on Trauma of the American College of Sur-
geons. This achievement recognizes the trauma
center’s dedication to providing optimal care for
injured patients.
Recognized by the American College of Surgeons
as an Accredited Comprehensive Bariatric Center.

18 HealthCare Business News I september 2019 www.dotmed.com/news

Specialties:
Cardiology/Cardiovascular Surgery; Bariatrics/
Weight Loss; Cancer and Infusion Services; Trau-
3
ma Program (we are a Level II Trauma Center);
Geriatric Primary Care

Recent developments:
Opened in 2017, the Center for Clinical Cardio-
vascular Care offers a suite of specialty services
for comprehensive and integrated cardiovascular
patient care. An additional improvement to the
heart program includes a new catheterization lab.
The Imaging Suite is a 24/7 subspecialty ser-
vice with state-of-the-art scanning equipment,
including the use of MR and CT for neuroimag-
ing, cancer imaging, and cardiac imaging.
A new Surgery Practice Space opened in July
2019, featuring a modern design, with 14 extra
rooms equipped with state-of-the-art technol-
ogy to evaluate patients for potential surgery
4
in several subspecialties, including General Sur-
gery, Bariatric Surgery, Surgical Oncology, and
Colorectal Surgery.
A future-state Cancer Center will feature
a comprehensive cancer program, providing
screenings, medical oncology, and surgical on-
cology. The Infusion Suite, which opened in
2018, is the first step in making this program.
The Ambulatory Care Center Lobby was ren-
ovated and reopened in May 2018.
The Main Hospital Lobby will be revamped next
year. In 2020, we will also be adding a single-bed-
ded inpatient unit and a medicine practice space.

1. Members of the Mount Sinai St. Luke’s

Emergency Department.
2. John D. Puskas, M.D., chair of Cardiovascular
5
Surgery at Mount Sinai St. Luke’s and Mount
Sinai West, and Gianluca Torregrossa, M.D.,
perform the Mount Sinai Health System’s first
TECAB surgery.
3. The new Ambulatory Care Center lobby and
façade opened in May 2018.
4. The new Infusion Suite at Mount Sinai St.
Luke’s serves as an extension of the highly
regarded Tisch Cancer Institute at The Mount
Sinai Hospital.
5. Screens in the new Daily Management and
Incident Command Center display real-time
data for areas throughout the hospital, en-
abling staff to track patients during their stay
and monitor flow, admissions, discharges, and
other clinical operations.

HealthCare Business News I september 2019 19

 Hospital Spotlight
HealthCare Business News spoke with
Art Gianelli, MBA, MPH, president of
Mount Sinai St. Luke’s, to get the de-
tails his unique background brings to his
role, and to hear his insight about the
hospital and healthcare overall.
HCB News: What inspired you to pur-
sue a career in healthcare?
Art Gianelli: My path was not a tradi-
tional one. I worked for a significant time in
local government: first, as a director of op-
erations for a town, then as a deputy county
executive for budget and finance. My ex-
pertise was in finance, turnaround manage-
ment and strategic planning.
While I was deputy county executive, I
was approached by the consultants the
county had hired to help develop a strategic
plan for its affiliated public hospital. The hos-
pital was chronically challenged, financially
and otherwise. The consultants wanted me
to run the hospital. I laughed. I told them I
had not run a hospital before, I’d been suc-
cessful in my career, but that’s a challenge
not like any other. And no one had been
successful historically in running that hos-
pital. However, the more I thought about it,
I believed in the hospital’s mission and the
population it served and I decided to look
at it as a real opportunity. I decided to take
a chance and go for it. I advised the consul-
tants that they needed to persuade my wife,
who was adamantly opposed to this, being
very familiar with the hospital and its history.
But they were able to persuade her as well.
I took the leap and started my tenure.
Given the constraints we were under and the
20 HealthCare Business News I september 2019
Q&A with
Art Gianelli
president of Mount Sinai St. Luke’s
Delivering healthcare in a 'Lean'
framework
By Sean Ruck
challenges facing that institution, I think we did
really remarkable work in terms of improving
quality and safety and starting to recover the
finances of the hospital. We also reinvested
in the hospital in ways that hadn’t been done
previously. We also encouraged the staff to
believe that transformation was possible. And
finally, I joined a number of boards across the
country. I was on the executive committee of
America’s Essential Hospitals, the regional pol-
icy board for the American Hospital Associa-
tion, the executive committee for Healthfirst.
My goal was to gain knowledge and insight
into running a hospital. Now, I actually teach
hospital operations at Columbia University and
at Mount Sinai. I’m proud of that, because it
wasn’t too long ago that I was just embarking
on a career as a healthcare administrator.
HCB News: How long have you been
with Mount Sinai St. Luke’s?
AG: I’ve been with the Mount Sinai
Health System since February 2014.
HCB News: What attracts staff to
Mount Sinai St. Luke’s?
AG: Similar to my prior hospital, Mount
Sinai St. Luke’s needed a turnaround strat-
egy. That was very clear to the leadership at
Mount Sinai and that was my charge here at
St. Luke’s. There’s been well over $100 million
of capital investment to build an ambulatory
platform, to upgrade equipment, to replace
the EMR, to transform the appearance and
operation of the organization. There have also
been investments in the hiring of staff to cover
gaps in our hospital service, and we’ve hired
staff to keep up with the volume growth that’s
occurred. We’ve targeted certain services to
expand and grow — cardiology, cardiac sur-
gery, bariatric surgery, orthopedic trauma,
cancer and our geriatric program.
Staff are attracted to the opportunity to
work for the Mount Sinai Health System. They
are also attracted to working for a hospital
whose services are growing and increasing in
complexity. Mount Sinai St. Luke’s is a Lean
hospital. When I first came to Mount Sinai,
I advised Dr. Ken Davis, the president of the
Mount Sinai Health System, that my experi-
ence of running a hospital was through a Lean
framework and that’s what I wanted to do here
at St. Luke’s. He was absolutely encouraging.
From day one, that’s what we’ve done here.
We’ve used Lean to develop our daily manage-
ment system, for process improvement and to
galvanize and energize the culture.
It’s evident to anyone who comes here,
that the experience of working at St. Luke’s
is different than at other hospitals. Here, the
wisdom of the frontline staff is valued and
cultivated. We want our frontline workers
to be emissaries of problem solving. I think
people who are attracted to that and that
level of agency with respect to their work,
really want to come here. We also try to em-
phasize the tenets of a just culture. Errors,
when they do occur, are typically associated
with system and process failures.
HCB News: Can you tell us roughly
what the makeup of your patients is
from a payor perspective?
AG: About 85 percent of the patients that
receive care at Mount Sinai St. Luke’s are in-
sured by the government, either through Medi-
www.dotmed.com/news
cade or Medicare. Any hospital that has that
ratio of government to commercial payors is
going to have challenges. Part of our strategy
is to develop and grow programs that can
diversify our payor mix. Certain services have
diversified quite nicely. Our bariatric surgery, as
an example, has seen our payor mix change sig-
nificantly from an overwhelmingly government
payor mix to one that is balanced. It’s a small
part of our business, but important. We have
to identify other services that can help us diver-
sify the types of patients and payors that come
here. It’s challenging, but important work.
HCB News: Our interview is taking
place in June, which was designated as
Pride month a decade ago. I saw on the
Mount Sinai website in the “about us”
a section dedicated to LGBT Health. The
section is extensive and also shows LGBT
champions dating back to 2015. Were
there any challenges to being able to po-
sition Mount Sinai as an LGBT advocate?
AG: That’s an interesting question. I will
tell you that the Mount Sinai Health System is
fully committed to LGBTQ care and to advo-
cacy on behalf of LGBTQ patients. That ranges
from specific programs we offer — one of our
hospitals is a center for excellence for trans-
gender surgery — to the approach we take
with respect to patients who arrive at our hos-
pitals. There’s training we do systemwide with
our frontline staff regarding pronoun usage,
respecting the desires of our patients regard-
ing how they identify themselves and how
they want to be identified by their caregivers. I
think that’s part and parcel to the value Mount
Sinai places on patients and employees.
It’s also part and parcel to the history of
our hospitals. Mount Sinai was founded
in 1852 for people who were Jewish at a
time when the Jewish residents of New York
couldn’t get care at certain hospitals. So
there’s a long history of Mount Sinai identify-
ing with and seeking to support people who
have been historically oppressed or discrimi-
nated against. That’s also another reason I’m
really proud to be part of this system.
We see all sorts of patients that are at
the margins of society and we believe very
strongly it’s our responsibility and obligation
to stand up for them and ensure that they
receive the best level of care.
HCB News: What else do you think is
unique about Mount Sinai?
AG: I would say that the staff is not only
second to none, but they are really culturally
unique. It’s a very family-oriented organiza-
tion. That’s evident in terms of how staff in-
teract with each other and how they interact
with patients.
In terms of services, the main growth
area for St. Luke’s since the merger with
Mount Sinai has been in cardiology and car-
diac surgery. Every element of our cardiology
and cardiac surgery programs has grown
significantly over the last five years. We have
world-class physicians leading the way. It’s a
remarkable transformation since I first got
here, and we’ve seen remarkable growth
while maintaining the highest possible level
of quality and safety. Mount Sinai St. Luke’s
is also a long-standing trauma center with
stellar orthopedic trauma surgeons who
have grown their practice significantly over
the last several years.
We have a solid general surgery program
which includes our trauma program, but also
includes vascular and bariatric surgery as well
as surgical oncology. The System Chief of
Surgical Oncology is also the Chairman of
Surgery for Mount Sinai St. Luke’s and Mount
Sinai West. We are thoughtfully and carefully
expanding our cancer program. Last year, we
opened an infusion suite and we’re hiring ad-
ditional clinicians to provide targeted medical
and surgical oncologic services.
We’re installing a PET CT through the gen-
erosity of a grant secured by our New York
City councilman, Mark Levine. And finally,
we’re privileged to be hosting the geriatric
program from Mount Sinai, since this program
is ranked by US News and World Report as the
third best geriatric program in the country.
HCB News: Healthcare is an ongoing
problem both in the political arena and
in the actual practice of delivering care,
due to continually rising costs, coordina-
tion of care, etc. If you had one wish for
something you could introduce to help
solve the problem, is there something
that comes to mind?
AG: I would like to have two wishes. First,
I think the macro political debate that we’re
HealthCare Business News
having — should we have single payor, fix
the ACA, do something else? — misses the
point. The challenge right now is how do we
deliver really good healthcare to our patients
that is both affordable and can be sustained
by our healthcare delivery system? I would
argue that the “Medicare for All” debate is
a false debate because it suggests that the
way we’re going to address the cost of care
is through the government dictating what
will be paid for health care services. I’m con-
cerned about that price point being set at a
level that’s not sufficient to sustain the qual-
ity of services we need to provide to patients.
The real debate should be about how
we can organize the delivery system in a
way that reduces waste significantly such
that we can change the trajectory of health
care costs. Some estimates have pegged the
waste generated by our health care delivery
system at $750 billion annually. One of the
reasons we’re committed to Lean at Mount
Sinai St. Luke’s is because its focus is the
elimination of waste and the introduction
of value to the patient through innovation.
The second wish I would make — and
it’s one of the things I talk about at Mount
Sinai — is about our ability to innovate. The
types of discoveries and the science that’s
happening here at Mount Sinai, it makes
me immensely proud to be part of it in my
small way. But we, as an industry, need to
innovate for the day-to-day with the same
enthusiasm and urgency that we apply to
finding a cure for cancer. Patients need to
experience a health care delivery system that
is seamless, integrated, connected, clear and
understandable. We need to do that. We
need to innovate at that level. There are
places in the country that do it well. I think
Mount Sinai is on the way to doing it well.
We need to foster that type of commitment
to day-to-day innovation and improvement
throughout the health system in the United
States. If we could do that, we would begin
to impact cost, wring out waste and change
how healthcare is delivered. My fear is that
our political debate obscures this reality —
where the real action should be occurring.
My hope would be that we change what we
talk about to talk about this.
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I september 2019 21
 IT Matters

EHRs, digital imaging and the

slow evolution of interoperability
By Sean Ruck

Dr. Chris Roth
Hospitals and doctors are required to
use electronic health records or get hit
with financial penalties under Medicare
reimbursement rules. While the rules have
been around for years and most providers
are following them, it doesn’t mean it’s been
easy or that data improvement is where it
needs to be today.
Part of the problem is the fact that in-
teroperability, even among the same type
of technology, hasn’t met the expected or
promised standards. Different vendors have
had different levels of success, but that’s easy
to understand. After all, putting a lot of re-
sources into ensuring your tech plays well
with a competitor’s technology while having
no assurances that they’re doing the same,
is a tough pill to swallow.
Dr. Chris Roth, associate professor of
Radiology, vice chair Information Technol-
ogy and Clinical Informatics, director of Im-
aging Informatics Strategy at Duke Health
explained the even greater interoperability
challenge that’s found between imaging in-
formatics and EHRs. “Compared to many
other areas of medicine, Interoperability in
imaging is unique because you’re dealing
with a unique imaging format and com-
munications standard in DICOM,” he says.
Fortunately, many in the imaging commu-
nity are working to bridge the data divide
between imaging and the EHRs. When you
consider the spectrum of clinical multimedia
in radiology, cardiology, ophthalmology, ob-
stetrics, the emergency department, opera-
tive suites, dermatology and other medical
specialties, the opportunity is significant.
Most providers have the ability to take a
patient photo or video, integrate it into the
electronic medical record, and assign some
straightforward metadata to it using the In-
tegrating the Healthcare Enterprise Radiol-
ogy’s Encounter Based Imaging Workflow
(IHE EBIW) profile. But this profile requires
build work within and between institutions
to create appropriate clinical workflows and
interoperable data. “When capturing imag-
es, medical professionals often still disagree
with the terms to use to describe the body
part,” says Roth. The HIMSS-SIIM Enterprise
Imaging Community is tackling this challenge
to determine the optimal ontology to consis-
tently describe body parts. Roth continues,
“Pretend there is an open fracture of the
upper arm. The big bone in an X-ray of the
upper arm is called the humerus. Taking a
photograph of the broken bone sticking out
of the same upper arm, the body part might
be described as arm or skin. True interopera-
bility means the X-ray and the photo need to
relate to each other in computer terms, and
we must agree on those terms, so providers
can consume them in the EHR together.
So it’s clear that the technology at many
sites isn’t exactly delivering what’s needed for
interoperability with imaging. But how well
are imaging departments complying? In a
broad sense, not too well. Part of the blame
lies with the vendors, with different vendors
having different ways of labeling very similar
techniques and different ways of capturing
and incorporating images into the systems,
meaning the task is exponentially harder the
more systems the radiologist has to work with.
Part of the blame lies with physicians and hos-
pitals permitting imaging metadata variation.
Different scanner manufacturers call
nearly identical sequences by different
names. Different scanners within a hospi-
tal may or may not have similar imaging
metadata, depending on who configured
the scanner, the scanner age, and how long
ago those metadata were last reviewed.
Until recently, there was no ability to cen-
trally modify and standardize the image data
capture configurations on many devices at
once. Integrating the Healthcare Enterprise
Radiology recently created a profile called
Management of Acquisition Protocols (IHE
MAP) so that a leader technologist and
physician can jointly and centrally review
and modify the configurations of the entire
scanner fleet, permitting consistent meta-
data capture, even across scanner vendors.
“Most hospitals around the country keep
scanners for more than five years, often up
to 10 years,” Roth says. “Some scans will
always only have older sequences, and thus
older metadata describing them unless the
institution puts in the effort to standardize
how they capture scans. IHE MAP can assist
with this data standardization and should be
requested of scanner manufacturers during
the RFP process as a play toward imaging
data interoperability.”  
The inconsistencies create at least one
additional source of friction. AI, which re-
lies on accurate and consistent data as its
lifeblood, suffers. A radiologist who verbally
dictates in a less-structured way what they’re
seeing, either due to limited technology or to
preference, isn’t adding clean and clear data.
On the other hand, a radiologist with current
technology and a mind for innovation may
use more structured terms computers can
understand.
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22 HealthCare Business News I september 2019 www.dotmed.com/news

 Cost Containment Corner
Cost-effective solutions for
healthcare IT deficiencies
By James D’Arezzo
Managing health-
care these days
is as much about
managing data as
it is about manag-
ing patients them-
selves. The tsunami
of data washing over
the healthcare industry is a result of techno-
logical advancements and regulatory require-
ments coming together in a perfect storm. But
when it comes to saving lives, the healthcare
industry cannot allow IT deficiencies to be-
come the problem rather than the solution.
According to a recent report from Inter-
national Data Corporation, the volume of
data processed in the overall healthcare sec-
tor is projected to increase at a compound
annual growth rate of 36 percent through
2025, significantly faster than in other data-
intensive industries.
Healthcare faces many challenges, but
one that cannot be ignored is information
technology. Without adequate technology
to handle this growing mountain of often
complex data, medical professionals and sci-
entists can’t do their jobs.
Electronic health records
Over the last 30 years, healthcare organiza-
tions have moved toward digitizing patient
records, with 96 percent of U.S. hospitals
and 78 percent of physician’s offices now us-
ing EHRs, according to the National Acade-
my of Medicine. A recent report from market
research firm Kalorama Information states
that the EHR market topped $31.5 billion in
2018, up 6 percent from 2017.
The adoption of EHRs is supposed to be
a solution, but instead it is straining an over-
burdened healthcare IT infrastructure. This is
largely because of the lack of interoperability
among the more than 700 EHR providers.
Healthcare organizations, primarily hospitals
24 HealthCare Business News I september 2019
and physicians’ offices, end up with dupli-
cate EHR data that requires extensive (not to
mention non-productive) search and retriev-
al, which degrades IT system performance.
More data, more problems
IT departments are struggling to keep up with
demand. Like the proverbial Dutch boy with
his finger in the dyke, it is difficult for IT staff to
manage the sheer amount of data, much less
the performance demands of users.
The applications are getting more robust,
systems are generally more reliable, but
speed (performance) is a constant challenge
that can get worse by the day.
From an IT investment perspective, im-
provements in technology have given us
much faster networks, much faster process-
ing and huge amounts of storage. Virtualiza-
tion of the traditional client-server IT model
has provided massive cost savings. And new
hyperconverged systems can improve per-
formance as well in certain instances. Cloud
computing has given us economies of scale.
But costs will not easily be contained,
as the mounting waves of data continue to
pound against the IT breakwaters.
Containing IT costs
Costs continue to rise, proportionate to the
demand for the three fundamentals (appli-
cations, uptime and speed).
However, there are solutions that can help
contain IT costs. Data Center Infrastructure
Management software has become an effec-
tive tool for analyzing and then reducing the
overall cost of IT. In fact, the U.S. government
Data Center Optimization Initiative claims to
have saved nearly $2 billion since 2016.
What is often overlooked is that processing
and analyzing data is dependent on the over-
all system’s input/output performance. Many
large organizations performing data analytics
require a computer system to access multiple
and widespread databases, pulling information
together through millions of I/O operations.
The system’s analytic capability is dependent
on the efficiency of those operations, which,
in turn, is dependent on the efficiency of the
computer’s operating environment.
In the Windows environment especially
(which runs about 80% percent of the world’s
computers), I/O performance degradation
progresses over time. This degradation, which
can lower the system’s overall throughput
capacity by 50 percent or more, happens in
any storage environment. Windows penal-
izes optimum performance due to server inef-
ficiencies in the handoff of data to storage.
This occurs in any data center, whether it is in
the cloud or on premises. And it gets worse
in a virtualized computing environment. In a
virtual environment the multitude of systems
all sending I/O up and down the stack to and
from storage create tiny, fractured, random
I/O that results in a “noisy” environment that
slows down application performance. Left un-
treated, it only worsens with time.
While additional hardware can temporar-
ily mask this degradation, targeted software
can improve system throughput by up to 30
to 50 percent or more. Software like this has
the advantage of being non-disruptive (no
ripping and replacing hardware), and it can
be transparent to end users as it is added in
the background. Thus, a software solution can
handle more data by eliminating overhead, in-
creasing performance at a much, much lower
cost and extending the life of existing systems.
With the tsunami of data threatening IT,
solutions like these should be considered in
order to contain healthcare IT costs.
James D’Arezzo is CEO of Condusiv Tech-
nologies, a global provider of software-only
storage performance solutions for virtual
and physical server environments.
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 Flash Therapy
Looking toward a future
with flash therapy
By John R. Fischer
Researchers at the Institut Curie in Or-
say, France made history in 2014 when
they performed the first demonstration
of flash radiotherapy, a technique that
delivers large doses of radiation in a
fraction of a second. Applying short pulses
of radiation to the thorax of mice at a dose
rate of more than 40 Gy/s, the team exam-
ined the extent of lung fibrogenesis in the
specimen for up to six months after radia-
tion, and found that normal, healthy tissue
sustained less damage, compared to that of
mice irradiated at a conventional dose rate.
“We use a single dose treatment,
meaning that the entire treatment is given
26 HealthCare Business News I september 2019
at once to a single participant in a short
sequence,” Dr. Vincent Favaudon, the
developer of the technique at the Institut
Curie, told HCB News.
Since then, flash demonstrations have
been conducted throughout Europe and
the U.S., with researchers aiming to adapt
the practice for clinical use and improve the
speed and safety of radiotherapy. To do this,
however, requires a thorough understanding
of flash, as well as answers to unanswered
questions around its use and impact.
Sculpting dose and sparing tissue
The speed at which doses are delivered
during flash therapy helps reduce damage
incurred by healthy tissue surrounding the
tumor. Treating cancer this way, whether it
be a single session or multiple sessions, is ex-
pected to have a dramatic impact on patient
outcomes and also hospital throughput.
“The dilemma in many cases is that the
tumors are not physically separate from
certain, critical normal organs. They are
sort of ‘weaved’ in,” said Dr. Billy Loo, a
professor of radiation oncology at Stan-
ford University. “Even if you’re sculpting
the dose very carefully, you’re ultimately
going to be limited in how much radiation
you can apply because the normal tissues
www.dotmed.com/news
are right there. With flash, we are develop-
ing strategies both to create highly sculpted
doses and deliver them super fast to maxi-
mize the sparing of normal tissues."
Most of the research using flash so far
has been done in preclinical studies and we
are still a long way from introducing flash
therapy to the clinical setting. The type of
radiation most commonly used for these ex-
periments to date is electrons, though some
demonstrations have used protons and syn-
chrotron X-rays.
“Flash is not necessarily minimizing neces-
sary physical dose to the normal tissue, but
when radiation is delivered at very high dose
rates, the healthy tissue apparently does not
‘see’ it,” said Dr. Zeljko Vujaskovic, a profes-
sor of radiation oncology at the University of
Maryland School of Medicine. “Therefore, the
normal tissue is not responding to this high
dose in the same way it would with protons or
photons. The damage from this ‘flash effect’
in normal tissue, at least based on some pre-
clinical work, is less than with standard proton
or photon therapies. The mechanism underly-
ing this phenomenon is unclear.”
Potential applications for
flash therapy
The speed and specificity of flash therapy
make it particularly promising for cancers
where treatment currently requires mo-
tion management. For example, with lung
cancer, conventional radiotherapy calls for
synchronizing the beam with the breathing
cycle to target moving tumors at specified
locations.
“That was one of the original motiva-
tions behind the idea and advantage of su-
per fast radiotherapy,” said Loo. “If we can
flip the problem around so that the treat-
ment is almost instantaneous, it becomes
so fast that all of the motion in the body is
essentially frozen. That will allow us to give
the most precise, highly sculpted radiation
doses to tumors, while also capitalizing on
the biological benefits of flash to spare nor-
mal tissues.”
In April, Vujaskovic and his colleagues
from the University of Maryland department
of radiation oncology unveiled lung cancer
research as part of their first quantitative,
preclinical findings using flash therapy with
protons. The researchers recorded 25-30
percent less damage to lung tissue, leading
to less fibrosis of the lung, and an average
35 percent decrease in skin dermatitis when
using flash. 
It is the first of any flash demonstrations us-
ing protons rather than electrons to show sig-
nificant reductions in lung injury, according to
Vujaskovic, who described flash therapy with
electrons as being primarily suited for superfi-
cial tumors (such as those of the skin). “With
protons,” he said, “this type of treatment can
be delivered to deep-seated tumors.”

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HealthCare Business News I september 2019 27

 Flash Therapy
Billy Loo
A long road ahead
Despite the potential benefits of flash thera-
py, important questions remain unanswered
and technological advancements will be
necessary.
While preclinical research is a good start-
ing point, Dr. Hans Langendijk, professor
and chair of the department of radiation
oncology at the University Medical Center
in Groningen in the Netherlands, cautions
that it lacks essential information in a num-
ber of its findings. The most important of
these critiques, he said, includes the need
for radio-biological experiments to confirm
that first results can be replicated under dif-
ferent circumstances, and assessments of
potential late-term outcomes.
Vincent Favaudon “What we see in radiation therapy is
acute toxicities that may occur during the
course of radiation and immediately after
radiation,” he said. “Most of these studies
have been focusing on those complications,
but the mechanisms that may result in late
complications — which, in some cases, may
occur even 10-15 years after — are com-
pletely unknown.”
Fractionation is another area where Lan-
gendijk said work needs to be done.
“The first question is IF we have to frac-
tionate or not. The second issue is when
you give the entire treatment in just a frac-
tion of a second, you have to be very sure
that the dose delivery is correct, which re-
quires intense physics quality assurance.”
Zeljko Bringing flash to the clinic will also re-
Vujaskovic quire better equipment because existing
linear accelerators are incapable of deliver-
ing radiation doses at the required speed.
Loo and his colleagues at Stanford are
working to change this by partnering with
the SLAC National Accelerator Laboratory
in an ongoing program called PHASER,
which incorporates multiple technological
advantages aimed at delivering ultrafast
radiation treatment.  will find a role in radiation oncology,” said
Developing the technology to deliver
flash is itself a two-fold challenge. Making
those capabilities viable for actual health-
care providers means that financial consid-
erations must also be made.
28 HealthCare Business News I september 2019
“Cost of technology has to be reduced
and designed for better economy, compact-
ness and compatibility with available infra-
structures so you don’t have to build new
buildings just to put in a machine,” said Loo.
“There needs to be better automation and
clinical efficiency so that more patients can
be treated on any given system in any given
amount of time.” 
From there a host of new questions open
up, such as how to train medical personnel
on using the technology and how to ensure
patient access to the treatment, which will
depend on health policies, healthcare sys-
tems and local politics of individual countries
and insurance companies.
One step at a time
While flash may be years away from be-
ing used on patients in everyday settings,
a great amount of progress has been made
around it, including the introduction of clini-
cal trials for humans.
“If successful, we could treat patients in
a fraction of a second, instead of in seven
weeks, with less radiation-induced com-
plications, and with a very high probability
to obtain tumor control,” said Langendijk.
“This may be one of the most exciting de-
velopments I’ve seen in my career.”
The aim behind flash therapy is not
just to enhance treatment efficiency but
access at lower costs, according to Loo.
“Our goal is to develop technology to al-
low flash ultimately to be used in place of
existing radiotherapy, enabling it to bring
down price and open up greater access to
lifesaving treatments for patients.” 
Those are big goals, and achieving
them will require the accumulation of
evidence to illustrate its benefits. On this
front, there is still a tremendous amount
of work to be done.
“I am optimistic, and do believe flash
Vujaskovic. “It will be a major step forward
in how radiation is delivered, but again, we
need to have more solid, firm data to move
this to become a standard of care.”
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 Equal Opportunities
Addressing gender
disparities in the
field of radiation
oncology
By Dr. Luca Valle and Dr. Ann Raldow
Conversations surrounding pervasive inequities in all aspects
of the workforce are now having their long overdue moment
in the spotlight of American society, and healthcare is no
exception.
Paradoxically, perhaps because the field of medicine attracts
a select group of forward-thinking, emotionally intelligent, and
logical people motivated to help others, many have been lulled into
believing that gender disparity in medicine does not exist, or when
it does, it exists for purely rational reasons. For example, while nu-
merous studies have described the trend of men earning more than
women at many stages of their careers, these differences are often
attributed to different career choices made by men and women in
medicine, including the decision to enter less remunerative special-
ties and work fewer hours.
30 HealthCare Business News I september 2019
Yet, other high-impact studies led by Dr. Reshma Jagsi and col-
leagues have suggested this may not be the case, since substantial
unexplained salary gaps have been proved to persist even after ad-
justing for specialty, academic productivity, and work hours.
Within the field of radiation oncology, gender has been shown
to influence many aspects of a physician’s career, including oppor-
tunities for academic advancement, scholarly activity, invitations to
participate in scientific panels, funding for physician researchers, and
even disease sites treated.
As a new trainee in radiation oncology who has always had an
interest in understanding and mitigating inequities as they manifest
in healthcare, I was curious as to how gender might be influenc-
ing salary and clinical activities in our field. Shortly after starting
residency at the University of California Los Angeles, I sought out
www.dotmed.com/news
the mentorship of Dr. Ann Raldow, who is a member of the UCLA female radiation oncologists in the facility-based setting collected
Jonsson Comprehensive Cancer Center, and we set out to tackle on average $33,026 less than their male counterparts. In the non-
the question of whether a disparity existed in clinical activities and facility-based setting, this gap was predictably wider, with similarly
reimbursement in the field of radiation oncology. highly productive females collecting an average of $345,944 less
We were both rather surprised to find that female radiation than males.
oncologists submit fewer charges to Medicare, are reimbursed less It is important to note that observational studies such as ours
per charge submitted and receive lower Medicare payments overall cannot establish an exact cause for the differential practice and re-
in comparison to male radiation oncologists. imbursement patterns we report, but speculating on some of their
driving factors is an important next step in determining how we
might level the playing field.
Within the field of radiation oncology, The first question to ask is: are these differential findings even
related to gender at all? It seems like an unavoidable conclusion,
gender has been shown to influence a but it is possible that there are other extraneous factors that we
did not control for in our study that are driving these results more
physician’s career, including academ- significantly than provider gender.
If, however, gender is indeed influencing our findings, either di-
ic advancement, scholarly activity, rectly or indirectly, this may be rooted in several factors. In terms of
clinical activity, less clinical activity may be a natural consequence
invitations to participate in scientific of the value-based labor choices that female practitioners make,
particularly within a gender-structured society where women
panels, funding for researchers, and continue to be expected to shoulder the greater share of domestic
responsibilities. However, less activity might also be tied to overt
even disease sites treated.
Our study was designed by querying a large database called the
Physician and Other Supplier Public Use File (POSPUF). This data-
base was created to increase financial transparency in the United
States healthcare system by tracking data on individual physician
reimbursements from Medicare. This allowed us to formally and
objectively characterize productivity and reimbursement patterns
among male and female radiation oncologists on a national level
for the first time.
We looked at payments in both non-facility-based (or freestand-
ing, often private practice) radiation oncology clinics, as well as
facility-based (or hospital-based, often academic) radiation oncol-
ogy clinics, since distinctions in billing practices would cause any
reimbursement in the non-facility-based setting to be higher due to
the collection of technical fees by physicians who own the machines
used to deliver radiation.
Delving into the details of the study, what we found was that
of the 4,393 radiation oncologists submitting claims to Medicare,
female physicians who worked in a non-facility-based setting sub-
mitted an average of 1,051 fewer charges and collected $143,610
less in revenue than male physicians. Female radiation oncologists
working in a facility-based setting submitted on average 423 fewer
charges and collected $26,735 less in professional revenue than
their male counterparts.
These discrepancies were even wider when making comparisons
in the group of radiation oncologists submitting the most Medicare
claims. Even among similarly highly productive radiation oncologists,

HealthCare Business News I september 2019 31

 Equal Opportunities
sexual discrimination leading to fewer referrals from surgical and
medical oncologists. It is also possible that in designing their clinic
schedules, women prioritize time spent with a given patient over
number of patients seen, and that prioritizing quality over quantity
results in fewer claim submissions to Medicare. And finally, there
may be less billing support in practices attracting female providers,
thereby resulting in a failure to capture services that are actually
being provided.
In terms of reimbursement, decreased collections for women
might be the natural consequence of gender-related decreases
in clinical activity described above. However, decreased volume
of claim submission alone is insufficient to explain the gap in
reimbursement, particularly when you consider our finding that
women also collect less per charge despite the fact that Medicare
A more complex yet critical challenge
is cultivating a workforce culture
where women are perceived as key
members of the treatment team and
valued as equals, as this will help
mitigate disparities both within
economic reimbursement and beyond.
reimburses male and female providers at the same rates. This is
likely due to women submitting different kinds of codes than
men, and the codes women submit are likely less well-remuner-
ated. Many female radiation oncologists, perhaps for reasons
of mentorship and patient demographics, elect to treat breast
and gynecologic malignancies, and both of these subfields of
radiation oncology rely primarily on 3D conformal technologies
and brachytherapy techniques that are on the lower end of the
reimbursement spectrum in terms of planning and delivery codes.
Additionally, value-driven management decisions based on the
communal attributes socialized into women (versus the agentic
attributes socialized into men) could partially explain a payment
differential. For example, when two equivalent treatment options
are available, it is possible that female radiation oncologists are
more likely to select the more cost-effective option. We have
seen this in other specialties, where women have been shown to
adhere more closely to clinical guidelines, forego costly interven-
tions, and engage in shared-decision making with patients more
frequently. And finally, since many of the most senior radiation
32 HealthCare Business News I september 2019
oncologists in our field are male, decreased seniority in practice
hierarchies could be resulting in fewer lucrative referral patterns
for the less senior female radiation oncologists.
In order to help distinguish amongst these potential etiologies,
we plan to look at the claims submitted by men and women over
this same time period to determine if there is a difference in the
types of services that men and women bill for. We also plan to dig
a little bit deeper into the population of physicians who collect the
most Medicare dollars to see if we can learn anything about how
billing patterns differ between men and women among those col-
lecting the highest reimbursements from Medicare. The answers to
some of these questions will be presented at our society’s annual
meeting (ASTRO) later this year in Chicago.
There are a number of action items for healthcare executives
and administrators looking for ways to mitigate this disparity.
Ensuring that adequate billing support is available to all providers
is key, as is assuring that there are no significant imbalances in
referral networks. These are relatively quick and easy interven-
tions that can make an impact while efforts continue to pinpoint
the source of the variation. A more complex yet critical challenge
is cultivating a workforce culture where women are perceived as
key members of the treatment team and valued as equals, as this
will help mitigate disparities both within economic reimburse-
ment and beyond.
It is our hope that these next steps will move us closer to un-
derstanding and deconstructing sex-based barriers for economic
advancement within the specialty of radiation oncology and we look
forward to making important strides in this direction.
We would like to acknowledge the expertise and input of the
other co-authors on this study, including Julius Weng, M.D.; Reshma
Jagsi, M.D. DPhil; Fang-I Chu, Ph.D.; Sumayya Ahmad, M.D.; and
Michael Steinberg, M.D.
About the authors:
Luca Valle, M.D., is
in his second year of
training as a radiation
oncology resident at
UCLA. His research fo-
cuses on health policy,
healthcare dispari-
ties, and health services. He is a graduate of Dartmouth Medical
School and is a member of the American Society for Radiation
Oncology. Ann Raldow, M.D., MPH, is an assistant professor in the
Department of Radiation Oncology at the David Geffen School
of Medicine at UCLA. She also is a member of the UCLA Jonsson
Comprehensive Cancer Center’s Cancer Control and Survivorship
Program. Dr. Raldow’s research focuses on therapeutic decision
making, cost-effective care, quality of life and health outcomes
assessments.
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 View From The Hill

Bill aiming to reduce prior

authorization delays for
cancer treatment introduced
in Congress
By John R. Fischer

In early June, a group of U.S. representatives introduced a new

bill that proposes a plan for reducing obstacles to cancer care,
including restrictive prior authorization practices. 
Named The Improving Seniors’ Timely Access to Care Act of 2019,
the bipartisan federal legislation aims to reform prior authorization to
prevent unnecessary delays in patient access to critical cancer treat-
ments, and enable radiation oncologists and other clinicians to use their
clinical judgment to prescribe the best course of treatment for patients. 
“There is legitimate concern that the administrative burdens asso-
ciated with prior authorizations might sometimes result in physicians
feeling forced to provide lower value care to avoid extra delays for
approval of care that they believe to be more clearly in the patient’s
best interest,” Brian D. Kavanagh, the immediate past chair for the
ASTRO Board of Directors, told HCB News when the bill was intro- tage plan by requiring the plans to relay relevant information, includ-
duced. “The physician is balancing what they believe to be the best ing annual disclosure of medical treatments subject to prior autho-
possible, most personalized course of treatment against the patient’s rization; the percentage of requests that are approved and denied;
mounting anxiety about delayed access to treatment. It is frustrating and the average time for approval. In addition, it supports the use of
that the initial denials imposed by benefits managers often occur be- an electronic prior authorization process to streamline decisions and
cause they use guidelines that are outdated and lag behind currently avoid unnecessary delays for certain procedures. 
accepted practice standards.”  “The best effects of the bill for patients would be to mandate
More than nine out of 10 physicians experience delays in provid- speed and transparency on the part of the companies engaged in
ing lifesaving treatments to their patients due to prior authoriza- managing health insurance benefits for those suffering from cancer
tion, with one-third equating the average delay to longer than one and other serious medical conditions,” said Kavanagh. “We hope
week, according to a nationwide survey conducted by ASTRO. Each some of the current built-in inefficiencies and delays with the current
week of delay in starting cancer therapy causes a 1.2 to 3.2 percent system can be eliminated so that patients can receive care in a timely
increase in the likelihood of death, and adds stress and anxiety to manner without unnecessary added angst.” 
patients who are already concerned about their health.  The bill has been endorsed by several leading health providers, pa-
Doctors or staff members who object to these delays or denials tient advocacy groups, and other organizations, and was introduced
can file appeals for review at a higher level within the Radiation On- by Rep. Suzan DelBene (D-Wash.), Rep. Mike Kelly (R-Pa.), Rep. Roger
cology Benefits Managers (ROBMs). Many, however, are often forced Marshall, MD (R-Kan.) and Rep. Ami Bera, M.D. (D-Calif.). 
to consult with one or more individuals who may or may not have “As a doctor, I’m proud to be co-sponsoring this long-needed
any training in oncology, while patients are left waiting, with no guar- legislation to help relieve administrative burdens on practicing physi-
antees that they will receive treatment. This adds emotional distress cians,” said Rep. Ami Bera in a statement. “Physicians spend far too
and prolongs symptoms that can adversely impact their quality of life.  much time on burdensome paperwork and seeking authorization
The new legislation seeks to increase transparency in the prior on certain items, when they can be spending that time taking care
authorization process by making clear what the regulations of the of their patients. This bill modernizes the process, and is a win for
ROBMs are to help clinicians in their decision-making. It also aims to physicians and patients.” 
reduce unnecessary delays for patients covered by Medicare Advan- Share this story: dotmed.com/news/47519

HealthCare Business News I september 2019 33

 MR-Guidance

Q&A with
Dr. Parag Parikh
director of MR-Guided Radiation Therapy and
director of GI Radiation Oncology
Henry Ford Cancer Institute
Discussing the value of MR-guided
radiotherapy
By Gus Iversen

Last November, Dr. Parag Parikh, joined waitlist for the ViewRay and we have dou- survival in patients who received high-dose
the radiation oncology department at bled our therapy staff to support this. MR-guided radiation therapy to the pan-
Henry Ford Cancer to lead its MR-guided creas, as compared with standard dose ra-
radiation program. HealthCare Business HCB News: We’ve been hearing a lot diation. This is the only study using ablative
News sat down with him to find out how recently about the cutting-edge capabili- doses of radiation given over 5 fractions, and
the new role is working out and why he feels ties of MR-guided radiation therapy. This has a goal of recruiting 133 patients.
that MR-guided radiation is such a promising is a field where Henry Ford is at the cut- We also have a study using 5 fractions of
field for the future of cancer treatment. ting edge. What kind of research are you radiation to treat prostate cancer, using the
currently conducting with these tools? MRI to help boost the dose of the dominant
HCB News: Can you tell us a bit about
your background in radiation oncology
and what it’s been like to join the team
at Henry Ford?
With the advent of the alternative payment model,
Dr. Parag Parikh: I attended medical
school and residency at Washington Univer-
essentially capitating both professional and
sity in St. Louis. I had an early interest in tech-
nology development for tracking moving
technical charges per diagnosis in 90 day events,
tumors and worked under Dr. Daniel Low
to investigate CT scanning of lung tumor
there is an incentive for improvement in outcomes
respiratory motion and implantable electro-
magnetic transponders that could be put
without increasing number of treatments.
into the lung to help guide radiation therapy.
I continued as a faculty member at Wash-
MR-guided radiation therapy machines are uniquely
ington University for 12 years, and our team
treated the first MR-guided radiation ther-
positioned to do this, allowing safe, effective
apy patient in the world in 2014. With the
novel adaptive MR-guided radiation therapy
treatments in one week or less for many diseases
trial by Drs. Lauren Henke and Jeff Olsen, we
realized that abdominal radiation therapy
traditionally treated over 5.5 weeks.
would never be the same. 
I returned home to Detroit to join Henry PP: We have several ongoing clinical tri- nodule of prostate cancer in each patient.
Ford in 2018. As the group with the longest- als. First, we are leading the national SMART Finally, we have a corollary study for brain
running clinical MR-linear accelerator pro- study [NCT NCT03621644]. This study builds tumor patients looking at new imaging in-
gram, it was like jumping into a well-running upon retrospective data (Rudra, Cancer Med- formation that may inform how or when to
automobile. We now have a one-month icine, 2019) showing an almost doubling of change radiation therapy for glioblastoma.

34 HealthCare Business News I september 2019 www.dotmed.com/news

 Henry Ford Hospital where Dr. Parikh
directs the oncology department's MR-
guided radiation therapy program.
HCB News: The MR environment has
unique shielding and safety demands. Is
the same true for MR-guided radiation
therapy? If so, what kind of strategies
are being used to make sure staff follow
protocols?
PP: The MR environment is new to most
radiation oncology departments and we
worked hand-in-hand with our radiology
colleagues to implement best practices for
MR safety. We are included in the hospital-
wide MR safety conferences and we also had
our staff take the same training as offered
to radiology staff. A robust safety culture
has prevented any MR safety-related events
in the two years our center has been open.
HCB News: Is MR-guided radiation
therapy still primarily in the research
phase or is it being used more clinically
for certain indications? What is the reim-
bursement situation like?
PP: There are now over 20 programs offer-
ing clinical MR-guided radiation therapy. For
almost all of the sites, it has certainly become
the standard of care for hepatobiliary cancers,
as well as small amounts of lymph node dis-
ease in the abdomen or pelvis. The ability to
visualize these tumors, control for respiratory
motion and change the radiation plan based
on stomach and intestine position allow safer
and faster ablative radiation doses.
The current reimbursement for MR-guid-
ed adaptive radiation therapy is favorable.
We will obtain reimbursement for additional
radiation therapy plans delivered during the
radiation course if the anatomy changes in a
meaningful fashion and these charges have
almost universally been accepted.
HCB News: Looking ahead, what role
do you imagine MR-guided radiation
therapy playing in cancer treatment a
decade from now? What challenges (in
terms of cost, access, illustrating ben-
efits, etc.) need to be addressed?
PP: The long-term radiation therapy
practice will need to show simultaneous
HealthCare Business News
clinical efficacy with heightened efficiency.
With the advent of the alternative payment
model, essentially capitating both profes-
sional and technical charges per diagnosis in
90 day events, there is an incentive for im-
provement in outcomes without increasing
number of treatments. MR-guided radiation
therapy machines are uniquely positioned to
do this, allowing safe, effective treatments
in one week or less for many diseases tra-
ditionally treated over 5 ½ weeks. More-
over, some users are using their systems to
do away with traditional simulation, which
will shorten treatment times further and im-
prove value for the patient. I see MR-guided
radiation therapy becoming a standard ma-
chine in any dual linear accelerator clinic.
Challenges being addressed currently are
treatment times, distribution of adaptive ra-
diation responsibilities to therapists from the
physician/physicists, and physician training.
For a technology that is less than five years
old, these steps are occurring rapidly.
Share this story: dotmed.com/news/48321
I september 2019 35
 ASTRO
The 2019 American Society for Radia-
tion Oncology (ASTRO) Annual Meet-
ing takes place this year from Septem-
ber 15th through the 18th at McCormick
Place West in Chicago. HealthCare Busi-
ness News spoke with ASTRO president, Dr.
Theodore DeWeese, vice dean for the Johns
Hopkins School of Medicine and the Sidney
Kimmel Professor in the Department of Ra-
diation Oncology and Molecular Radiation
Sciences at Johns Hopkins University, to learn
about his background and to get an update
on the organization.
HCB News: What inspired you to get
involved in healthcare?
Dr. Theodore DeWeese: When I was in
college, I came to realize just how much I loved
science in the broadest sense, meaning chem-
istry and biology and physics. I was very lucky
to have an opportunity to work in a laboratory
in the School of Medicine in Colorado. I didn’t
know at the time, but I was doing what we
would now term “translational research”. We
were developing an assay for a particular rare
disease and came up with a way to do that,
and then had an FDA-approved product. As
my first research project, and since I had no
framework, I just thought it was the coolest
thing ever and I had no idea what a rare op-
portunity that was for me.
I also have always loved people and vol-
unteering and did that in various ways in
college and with a variety of organizations in
Denver. The linkage of those two things, and
really the second in particular, that’s where
36 HealthCare Business News I september 2019
Q&A with
Dr. Theodore
DeWeese
ASTRO president
Raising the profile of radiation oncology
By Sean Ruck
my heart was — around the notion of help-
ing those who need it, and I have this great
interest and love of science and biomedi-
cine — what better place to do that than
in medicine? No one in my family had ever
been to college, much less medical school,
so I rolled the dice and actually was admit-
ted into medical school. All these years later,
I have loved every moment.
HCB News: What is on your agenda
as president of ASTRO?
TD: Broadly, there are two categories.
First, we want to engage all of our mem-
bers and support them in their role in caring
for patients with cancer. It means having to
fully educate the public and other physicians
about the unique role that radiation oncol-
ogy plays within the oncology care team
– particularly, that we are one of the most
effective modalities to cure patients.
There are very high demands for quality
and safety that come with the work we do.
That’s very important for the broader audi-
ence to understand our role as oncologists,
and is really key in all of this, so we want to
propagate a very clear and positive message
about those aspects of who we are.
The second is the continuous learning re-
quired of those of us in cancer, generally, and
radiation oncology, specifically, because it’s
a fast-moving field. We need to make sure
our members feel they are as contemporary
in their knowledge as possible in areas like
biomarker development, cancer genetics
and immunotherapy linkages with radiation.
I also would link that emphasis directly
with support for the research mission ASTRO
provides in order to move the field forward,
and to make sure our newest members in-
herit a thriving and dynamic field that con-
tinues to be centered on our patients.
HCB News: What are the biggest chal-
lenges facing ASTRO members today?
TD: I think the restrictive coverage poli-
cies that payors have is a real issue for us
and our patients. It is frequently a challenge
obtaining prior authorization for treatment,
which is associated with a large administra-
tive burden and cost. ASTRO has done some
work recently evaluating this topic across our
membership. It’s been very clear that nearly
uniformly — over 90 percent of our mem-
bers have said — patients have been delayed
in receiving radiation therapy because of re-
strictive prior authorization practices that are
employed by many insurers. When a patient
has a life-threatening illness, the associated
threat with delaying their care is just not a
healthy situation to be in whatsoever.
As it turns out, about two-thirds of those
denials that originally come from these prior
authorizations are overturned anyway. So
it’s a process that’s stressful, potentially risky
for the patient, and extremely expensive
and problematic for the healthcare team.
Most management of patients today is
multi-modality, for example, chemotherapy
plus radiation. These treatments have to
be sequenced very accurately, and when
there’s a delay in either side of that, it can
www.dotmed.com/news
throw everything off track. A week of de-
lay for bureaucratic reasons could turn into
a significant delay far beyond a week be-
cause everything needs to be resequenced.
HCB News: Other than what you pre-
viously mentioned, are there benefits to
being a member of ASTRO?
TD: The other portion of education, to be
a little more explicit, is the continuous learn-
ing through the various journals that ASTRO
provides. There’s also the education provided
through a myriad meetings we support. And
the third major aspect is the linkages ASTRO
creates with other professional organiza-
tions, which helps to create guidelines and
other materials that educate our members
and other oncologists on how to manage
their patients.
For continuing education, a number of
the articles in our publications qualify for
self-assessment CME. One can read the ar-
ticle, then take an online questionnaire that
asks some questions that show you grasped
the key highlights of the article. Being able to
support the busy clinicians by having this sort
of opportunity directly in the publications
they receive as a member of ASTRO, I think,
is a very important way to support their
needs and ensure a continuous level of edu-
cation used to the benefit of our patients.
HCB News: Are there any recent de-
velopments in the field you’re particu-
larly excited about?
TD: There are actually quite a number.
One of the most important advances over
the last six or seven years is the role of immu-
no-oncology. It’s been clear by several pub-
lications that the combination of radiation
therapy with some of the so-called check-
point inhibitors — the immuno-oncology
drugs — is more beneficial than the drug
alone. Melanoma, for example, is a disease
where this has been seen. Moreover, I think
it’s extremely exciting, we are beginning to
understand the molecular underpinnings
of how the radiation-checkpoint inhibitor
interaction is occurring. We are now coming
to a place where we can start to think about
screening patients to determine who would
most benefit from a particular approach.
Another development is molecularly tar-
geted radiation. This involves tiny molecules
that target cancer cells and have a radioiso-
tope linked to them. These small radiola-
beled molecules are injected into a patient’s
bloodstream and circulate in the blood,
binding to the cancer cells and delivering
radiation right to the cancer. Prostate cancer
is one of the places this is being developed.
There’s also the notion that radiation
oncology is performed in what is termed,
“closed loop medicine”. That is to say, you
see patients, do all the tests, design a plan,
test the plan before you deliver to the pa-
tient, the patient comes, and you reevaluate
right before you give it to them, and then
you treat them. That’s repeated every day. So
our field generates a tremendous amount of
data that can be mined with deep-learning
algorithms and other artificial intelligence
models. These models will to help us learn
who might need more or less radiation,
based on certain features seen in thousands
of patients before them that we mine from
these huge data repositories.
HCB News: What are you most ex-
cited about seeing or experiencing at
this year’s conference?
TD: There is a whole new learning style
we’re putting forward for the meeting — the
presidential course in particular. It’s meant to
be much more interactive. We are starting
with a topic that is somewhat controversial:
radiation therapy in the curative treatment of
metastatic disease. Our goal is to really engage
the audience in the topic with several “level
setting” talks with the goal of getting all of the
audience on the same page as to the state-
of-the-state of metastatic cancer. This will be
followed by an Oxford-style debate between
experts, which we will use as a platform for
much smaller breakout sessions where the
various aspects of that topic can continue to
be discussed and debated. It’s more interactive
between audience participants and the lectur-
ers and educators. We are excited to bring
this new format to ASTRO this year and really
hope it is a more enjoyable and engaging way
to educate our members.
This year’s conference has more focus on
health and healthy living, with activities like
HealthCare Business News
morning yoga and more healthy eating op-
tions. The schedule is less compressed, too,
and there’ll be much more time for people
to network.
HCB News: Can you give your predic-
tion as to how you think radiation oncol-
ogy will change over the next 10 years?
TD: I think, number one, radiation on-
cologists are natural conveners — bringing
other medical disciplines together to work
on behalf of patients. I think this is both a
result of just the nature of those who enter
our field as well as how we are trained. So
I believe you’ll see multidisciplinary teams
across the country more often being led by
the radiation oncologist.
I think you’ll see growing importance of
the management of patients with more ad-
vanced disease. Radiation therapy will be
used in combination with immunotherapy,
as one example. I don’t just mean for pallia-
tive care, but curative care.
I anticipate a growing involvement with
radiation pharmaceuticals. This is just another
way to deliver radiation therapy to our patients
but one where we have great expertise in who
to treat, given our oncologic training, as well
as in the dosimetry necessary to provide effica-
cious and safe treatment. Genetic medicine, as
I noted before, is going to be a really significant
portion of our field — in the research we con-
duct, the education we provide and the use of
it in daily management to guide us to the most
optimal and precise care for our patients.
Another growth area for us is research in
AI. We need to push forward in this arena to
learn how and where AI can be used in our
field to guide care we provide, and to do so
in an ethical way and in a manner that pre-
serves and enhances the physician-patient
relationship.
Something that is very important to me
is that we will push hard to create a more di-
verse radiation oncology workforce-one that
will allow ASTRO to have all voices around
the table, so that the best decisions can be
made. It is also key so we look far more like
the patients we see and treat every day. Ul-
timately, creating change that improves the
lives of our patients is most important.
Share this story: dotmed.com/news/48322
I september 2019 37
 ASTRO
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ASTRO 2019 Exhibitors
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Mobius Imaging — Booth 4638
Mobius Imaging is the premier developer and supplier of Airo®
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imaging system. The company will be providing live product demon-
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be able to observe Airo mobility, receive a hands-on demonstration of
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cations in Radiation Therapy through in-booth media presentations.
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38 HealthCare Business News I september 2019
accelerators, CT Scanners, PET/CT, MRI systems and more. As dedi-
cated partners, we offer start-to-finish solutions and a full range of
equipment related services including installation, parts support and
warranty. Far too many people around the world don’t have access
to the medical treatment and services they need. At ROS, we believe
we can change that. We can extend the life of valuable medical
equipment without compromising safety, quality or environmental
sustainability. We can help hospitals and clinics use their resources
more efficiently, make their budgets go further, and provide more
services to their patients.
Sun Nuclear — Booths 2624 & 3415
Sun Nuclear provides innovative QA solutions for Radiation Ther-
apy, Patient Alignment, and Diagnostic Imaging. Our mission is to
treatment of cancer. More than 5,000 cancer centers rely on us
for independent, integrated Quality Management. With a focus
on support, we aim to ease technology adoption, improve out-
comes and enhance workflows — so that healthcare providers can
achieve real results for Patient Safety. Visit us in Booths 2624 and
3415 for product demonstrations and in-booth talks. Learn more:
sunnuclear.com/astro.
Varian — Booth 1405
At Varian, we envision a world without fear of cancer. For more than
70 years, we have developed, built and delivered innovative cancer
care technologies and solutions to help clinical partners around the
globe treat millions of patients each year. We are harnessing ad-
vanced technologies like artificial intelligence, machine learning and
data analytics to advance cancer treatment and expand access to care
for patients globally. We call our approach Intelligent Cancer Care.
Please visit us in booth #1405 to experience firsthand our evolving
ecosystem of technologies for fighting cancer.
www.dotmed.com/news
ASTRO to host Annual Meeting
in Chicago, September 15-18
ASTRO will host its 61 st   Annual plans to address key challenges facing both professor of radiation oncology at the
Meeting at McCormick Place in Chicago, radiation oncology and the larger house of University of Toronto. She also directs the
September 15-18, 2019. The meeting will medicine, including physician burnout, re- palliative radiation oncology program and
feature updates on clinical trials, cancer strictive prior authorization practices and has led numerous phase I, II and III trials,
research and new approaches that involve workforce diversity. including trials that focused on the use of
radiation therapy in cancer treatment. Dr. Dawson leads a multidisciplinary personalized stereotactic body radiation
Complimentary registration is offered for team of cancer specialists in upper gastro- therapy (SBRT) for patients with liver can-
credentialed news professionals who wish to intestinal (GI) cancers at the Princess Mar- cer, who historically were not candidates
cover the meeting. garet Cancer Centre in Toronto and is a for radiation therapy.
The 2019 ASTRO Annual Meeting is expect-
ed to attract more than 10,000 oncologists, cli-
nicians, researchers and other health care pro-
fessionals from across the globe. Throughout MEET THE NEW
the four-day meeting, researchers will present
peer-reviewed abstracts on advances in clini-
cal care for cancer patients, while panels and
interactive case discussions featuring leading
experts will underscore the meeting’s theme,
“Innovate, Collaborate: Transform.”

Dr. Laura Dawson chosen as

ASTRO president-elect
The members of ASTRO
have elected four new of- A Better Fit for
ficers to ASTRO’s Board Your Workflow
of Directors. Laura Daw-
son, M.D., FASTRO, will The next CT SIM+™ and MICRO+™
begin her term as Presi-
lasers from Sun Nuclear have been
dent-elect in September
redesigned to support optimal
during the society's 61st
positioning precision, reinforced
Annual Meeting in Chicago, alongside Neha
housing with tool-free entry, and
Vapiwala, M.D., the new secretary/treasurer-
elect; Constantine Mantz, M.D., the new
workflow-optimized software.
Health Policy Council vice-chair; and Brian Mar-
ples, Ph.D., the new Science Council vice-chair.
“I am honored to be elected as ASTRO’s
president-elect. Radiation oncology is a Get a firsthand look in
highly effective intervention that most can- ASTRO Booth 3415
cer patients benefit from at some point dur-
ing the course of their disease. Unfortunate-
ly, not all patients have access to radiation
therapy, and there is a need for improved
public awareness about its benefits,” said
Dr. Dawson.
In her tenure as president-elect and sunnuclear.com
eventual chair of ASTRO, Dr. Dawson also

HealthCare Business News I september 2019 39

 ASTRO
ASTRO News
CDR Systems — Booth 1445
CDR Systems, a global patient positioning and immobilization solu-
tions provider introduces the PowerWEDGE™ for Radiation Therapy.
Calgary, AB CDR Systems launches the PowerWEDGE™ specifi-
cally designed to improve the experience for patients that struggle
with lying flat on their back, the most common treatment position for
the treatment of cancer using external beam radiation therapy. The
PowerWEDGE™ provides an angulation option for patient immo-
bilization that previously could only be offered in a lay flat position.
This new all-in-one medical device is designed to enhance patient
comfort and setup accuracy through improved comfort and is offered
with 8 additional module attachments ensuring patient setup can
be tailored for a wide range of treatment needs, including: cranial
stereotactic (SRS), Body Stereotactic (SBRT), head and neck, breast,
lung, liver, spine or pelvic treatments.
“It is clear a significant subset of the patient population struggle
to lay in a flat position and a solution that upholds inter and intra
patient positioning accuracy without compromising comfort was
needed. We have created the PowerWEDGE to answer just that. Carl
Denis, CEO at CDR Systems.
For an introduction to CDR Systems:
• Booth# 1445 at the ASTRO 2019 Annual Meeting, September 15
- 17, 2019 McCormick Place West Chicago, IL.
• Schedule a collaborative in person demonstration with a CDR prod-
uct specialist right in your radiotherapy department.
• Web based eDemo hosted by a CDR Product Specialist streamed
right to your conference room, tablet or personal computer.
• Toll Free: +1-855-856-7035 or www.cdrsys.ca
Hitachi — Booth 1039
The University of Texas M.D. Anderson Cancer Center has revealed
plans to more than double the size of its proton therapy center.
The $159 million project will expand the building to more than
160,000 square feet, enabling it to take in more patients who require
treatment with the advanced form of radiotherapy.
“We are excited to more than double our IMPT capacity in the
new center to approximate 100 patient treatments per day, better
ensuring timely patient access so that more patients can benefit from
this technology,” G. Brandon Gunn, associate medical director of
the Proton Therapy Center at the University of Texas M.D. Anderson
Cancer Center, told HCB News.
The expansion will include eight radiation therapy systems devel-
oped by Hitachi that rotate at 360 degrees around patients to deliver
therapy to the exact area that requires treatment, a technique known
as intensity-modulated proton therapy.
The center will also install an additional synchrotron, the accelera-
tor used to create proton beams, and rooms with improved, modern
designs for better patient experiences.
40 HealthCare Business News I september 2019
“One of the four treatment rooms in our current center is IMPT
capable and is in very high demand by our patients and physicians.
Proton therapy expansion at M.D. Anderson will greatly increase
patient access to IMPT, as all four treatment rooms in the new center
will be equipped with this advanced technology, more than doubling
our current IMPT capacity,” said Gunn. “The new center will feature
numerous technical advancements that will further improve proton
therapy delivery and precision, such as in-room CT volumetric imag-
ing and tumor motion tracking.”
The center experienced a nearly 11 percent increase from 2017 to
2018 in the number of patients who underwent proton therapy. The
expansion of the 73,500-square-foot facility is expected to provide
more accessibility to patients who would benefit greatly from PT. This
includes those with cancer of the head and neck, which currently
make up 38 percent of the cases at M.D. Anderson; prostate, lung,
liver, and brain, and a range of pediatric cancers.
The expansion is estimated to be completed by November 2023.
Construction will be carried out by Gilbane Building Company.
Varian — Booth 1405
At Varian, we envision a world without fear of cancer. For more
than 70 years, we have developed, built and delivered innovative
cancer care technologies and solutions to help clinical partners
around the globe treat millions of patients each year. We are har-
nessing advanced technologies like artificial intelligence, machine
learning and data analytics to advance cancer treatment and ex-
pand access to care for patients globally. We call our approach
Intelligent Cancer Care.
During ASTRO 2019, Varian will share a new comprehensive
adaptive solution that harnesses the power of artificial intelligence.
It’s an AI-driven adaptive solution that includes treatment planning,
delivery, and monitoring to fuel the next generation of adaptive
therapy. Varian’s Adaptive Intelligence solution is designed to
deliver high-quality treatments and incorporate diagnostic quality
MR, PET, and CT images during planning and treatment—enabling
the physician to choose the imaging appropriate for the cancer and
tumor type. Varian’s Adaptive Intelligence solution will empower
clinical teams to treat more precisely, so they can provide personal-
ized, optimized care for patients. Please visit us in booth #1405 to
experience firsthand our evolving ecosystem of technologies for
fighting cancer.
Leaders in radiation oncology awarded ASTRO
Fellow designation
The American Society for Radiation Oncology (ASTRO) has selected
26 distinguished members to receive the ASTRO Fellow (FASTRO)
designation. The 2019 class of Fellows will be recognized in Septem-
ber during ASTRO’s 61st Annual Meeting in Chicago.
www.dotmed.com/news
 The ASTRO Fellows program recognizes • Ramesh Rengan, M.D., Ph.D., University of • Catheryn Yashar, M.D., University of Cali-
individuals who have made significant con- Washington School of Medicine fornia, San Diego
tributions to the field of radiation oncol- • Ugur Selek, M.D., The University of Texas • Torunn Yock, M.D., MCH, Massachusetts
ogy and to the Society through research, M.D. Anderson Cancer Center-Istanbul General Hospital
education, patient care and service to the • Helen A. Shi, M.D., MS, MPH, Massachu- Fellows candidates must be nominated by
field. Since its inception in 2006, the FAS- setts General Hospital a current ASTRO Fellow, accompanied by
TRO designation has been awarded to just • Benjamin D. Smith, M.D., The University of three letters of support from ASTRO mem-
353 of ASTRO’s more than 10,000 members Texas M.D. Anderson Cancer Center bers. A committee reviews all nominations
worldwide. • Srinivasan Vijayakumar, M.D., University of and presents the candidates to ASTRO’s
“On behalf of ASTRO, I commend these Mississippi Medical Center board of directors for approval.
26 outstanding physicians and scientists for • Akila N. Viswanathan, M.D., Johns Hopkins
their collective and far-reaching contribu- Medicine
tions to our specialty, as well as for each in-
dividual's work to advance cancer research,
education and clinical care to improve pa-
tient outcomes,” said Paul Harari, M.D., FAS-
TRO, Chair of the ASTRO Board of Directors.
The 2019 Fellows are:
• Ron R. Allison, M.D., Federal Medical Center
• Felipe A. Calvo, M.D., Clinica Universidad
de Navarra
• Allen M. Chen, M.D., University of Cali-
fornia, Irvine
• Gregg Franklin, M.D., Ph.D., New Mexico
Cancer Center
• Joel Greenberger, M.D., UPMC Hillman
Cancer Center
• Michele Yvette Halyard, M.D., Mayo Clinic,
Scottsdale
• Daphne Haas-Kogan, M.D., Dana-Farber
Cancer Institute/Brigham and Women’s
Hospital
• Kathleen M. Hintenlang, Ph.D., The Ohio
State University
• Vivek Kavadi, M.D., Texas Oncology
• Paul Keall, Ph.D., The University of Sydney
• Larry L. Kestin, M.D., MHP Radiation On-
cology Institute
• Deepak Khuntia, M.D., Varian Medical
Systems
• David Kirsch, M.D., Ph.D., Duke University
Medical Center
• Sunil Krishnan, M.D., The University of
Texas M.D. Anderson Cancer Center
• Fei-Fei Liu, M.D., Princess Margaret Cancer
Centre
• Daniel Low, Ph.D., University of California,
Los Angeles
• Matthew Manning, M.D., Cone Health
• Rinaa Punglia, M.D., MPH, Dana-Farber
Cancer Institute

HealthCare Business News I september 2019 41

NEW
ASTRO
PRODUCT SHOWCASE
The following are just some of the products and services on display at ASTRO 2019. To view these
products online, or to share with colleagues, visit dotmed.com and enter the code DM 48330 in the
search window, or enter the address www.dotmed.com/news/48330 in your browser.

PRODUCT RectalPro75 ENDORECTAL BALLOON SBRT IMRT PROTON

QLRAD — Booth 4835

SHOWCASE QLRAD s RectalPro75 lowers toxicity, is patient friendly due to the anatomical shape
and is caregiver friendly. Immobilizes the prostate, reduces movement to have a
better day to day reproducibility due to a symmetrical balloon as well and spread
the rectum to be in low dose area.

MRgRT Motion Management Phantom

CIRS — Booth 4215
The integration of MR imaging in radiation therapy facilitates real time motion management. The CIRS MRgRT Mo-
tion Management QA phantom is designed to address such needs. The phantom is MR Safe due to piezoelectric
motors and non-ferro-magnetic materials. The moving insert contains an organic shaped target (tumor) filled with
gel, which is surrounded by the same background gel used to fill the body. The body represents a heterogenous
background due to simulated lungs, liver, kidney and spine. All organs as well as the moving target, except for the
lungs, offer ion chamber dosimetry capabilities. The simulated organs are anatomical in shape and have a life-like
spatial relationship. The phantom allows users to calculate the Beam Latency specific to hybrid MRI-Linac systems. 

Precision Laser Systems

Sun Nuclear — Booths 2624
& 3415
Sun Nuclear Precision Laser Systems -
CT SIM+™ with RapidSIM™ Software ProBeam® 360 Proton
and MICRO+™ - have been rede- HyperArc High-Definition Therapy System
signed to optimize your clinical work- Radiosurgery Varian — Booth 1405
flow. The CT SIM+™ moveable laser
Varian — Booth 1405 The ProBeam® 360 Proton Therapy System from
HyperArc™ high-definition radiotherapy Varian is defining next-generation proton therapy.
system supports your PET/CT Simula-
represents a significant step forward for It offers uncompromised clinical capabilities, with
tion workflow. Industry-leading preci-
linac-based radiosurgery. An intracranial ultra-high dose rates, a 360-degree gantry, and
sion and accuracy provide enhanced
radiosurgery solution that harnesses the exceptional precision, all within a 30% smaller
confidence for patient safety. A mod-
power of Varian’s TrueBeam® and Eclipse™ footprint. High dose rates are used today to re-
ern, unassuming design combined
platforms, HyperArc is a streamlined, end- duce treatment time, manage motion, and can
with accessible software allows your
to-end solution that can be adopted by improve treatment plan quality and conformity.
team to work unimpeded by physical
clinics worldwide to extend the benefits of We expect next-generation proton therapy to
or technological barriers. The MICRO+
radiosurgery to many more patients. Hyper- employ even higher and ultra-high dose rates.
fixed laser system supports fixed pa-
Arc SRS-specific optimization tools to opti- The ProBeam 360° System features the most
tient alignment for diagnostic imag-
ing and radiation therapy, including
SHOWCASE
mize dose and treatment delivery. Dedicat-
ed algorithms enable an efficient workflow
powerful particle accelerator available to treat
cancer. It incorporates RapidScan™ technology,
MR Simulation and MR linacs. Preview
that can be completed in a conventional which revolutionizes motion mitigation by deliv-
the newly redesigned laser systems in PRODUCT
radiotherapy time slot—even when treating ering each field within a single breath-hold for
ASTRO Booth 3415.
multiple targets simultaneously. most patients.

42 HealthCare Business News I september 2019

NEW www.dotmed.com/news
Hitachi — Booth 1039
The world’s only synchrotron-based single room solution, the synchrotron accelera-
WEN
tor technology allows for less shielding thus minimizing the overall size of the layout

TCUDORP
and the concrete cost to the building. Compared with our past layout, Hitachi has
minimized and optimized the configuration yet utilized the identical gantry and ac-
celerator technology which has been proven with our multi-room solution.

ESACWOHS
The combination of Hitachi’s 360 degrees compact rotating gantry and 30 x 40
cm irradiation field size enables users to widely treat many tumor sites. In addition,
Hitachi’s spot scanning technology allows Intensity Modulated Proton Therapy
(IMPT) under fully-integrated Image guidance with gantry mounted isocentric
CBCT. Our system is capable of interfacing with any motion management solu-
tions, treatment planning system and oncology information system.

Airo® TruCT 
Mobius Imaging — Booth 4638
Airo® TruCT is a 32 slice, mobile, larg-
est inner bore CT system which provides
intra-procedural diagnostic imaging for
applications in radiation therapy including
Proton Therapy and brachytherapy. Devel-
oped by Mobius Imaging, which special-
izes in standing diagnostic, interventional,
and intraoperative CT imaging systems,
Airo’s Point-of-Care CT imaging may re-
duce procedural time and help increase
treatment accuracy. 

PROTEUS®ONE 
IBA  — Booth 3028
IBA PROTEUS® family is the proton therapy platform of the future
with a comprehensive set of tools for motion management, with
a demonstrated spot-scanning proton arc therapy irradiation, and
finally, with an ultra high-dose rate capability for flash research.
PROTEUS®ONE is the only compact single-room image-guided
IMPT solution, allowing easy integration into a variety of healthcare
settings. Smaller and more affordable than conventional multi-
room proton systems, but with the same clinical applications. 

PROTEUS®PLUS
IBA  — Booth 3028
IBA PROTEUS® family is the proton therapy platform of the
future with a comprehensive set of tools for motion manage-
ment, with a demonstrated spot-scanning proton arc therapy
irradiation, and finally, with an ultra high-dose rate capability
for flash research.
PROTEUS®PLUS is a multi-room proton therapy solution with
the latest advances in precise, image-guided and intensity mod-
ulated proton beam delivery.

HealthCare Business News I september 2019 43

 Latest And Greatest
What's new in rad
and proton therapy
By Lisa Chamoff
Cancer treatment is getting faster and
more precise, with the future promis-
ing to usher in ultra-high, cancer-killing
radiation dose in less than a second. In
the here and now, manufacturers of proton
therapy and conventional radiation oncology
treatment systems are continuing to increase
speed and precision in an effort to create the
best outcomes.
Here’s what’s new in both proton therapy
and radiation oncology.
Proton therapy
Hitachi Proton
Treatment has begun at two proton ther-
apy centers in Japan: the Osaka Heavy Ion
Therapy Center, which began operating in
44 HealthCare Business News I september 2019
It’s possible that an ISO could order replace-
ment parts from the OEM at full price, only
IBA ProteusPLUS
to charge you an additional markup.
October 2018, and the Nagamori Memorial
Center of Innovative Cancer Therapy and
Research in Kyoto, which opened for treat-
ment in April 2019.
The site in Osaka, which has three treat-
ment rooms, is the first heavy ion therapy
center designed to be dedicated for dose-
driven continuous scanning technology. It is
one of only a few locations in the world to
offer the advanced form of particle therapy,
which uses more energy in the tumor tis-
sue, which can be more destructive to the
tumors, can treat radioresistant cells, and
requires fewer treatment sessions.
The site in Kyoto includes real-time image
gating motion management technology,
which allows treatment of tumors during
patient motion, according to the company.
This technology received FDA 510(K) clear-
ance in December 2017.
In June 2018, Hitachi acquired Mitsubishi
Electric Corporation’s particle therapy division.
“With the addition of Mitsubishi, we
have added 7 proton centers and 4 carbon
centers to our user group. We are extremely
happy with the progress of our synergies and
hope to see more growth in the near future”
said Sash Matsumoto, general manager at
Hitachi America Ltd.
IBA
IBA, which has roughly 30 proton therapy
systems in clinical operation around the
world, is working on developing a new mo-
tion management technology that is a mix of
beam management and image guidance to
freeze moving targets.
“The tumor in the lung that moves as a
patient is breathing — that’s what motion
management will address,” said Frédéric
Genin, chief product officer for proton ther-
apy at IBA.
It is also working with a partner in Royal
Oak, Michigan, to develop arc proton thera-
www.dotmed.com/news
SECURE THE FUTURE OF PROTON THERAPY

MOTION ARC FLASH

MANAGEMENT THERAPY1 THERAPY1

The right partner to increase delivery of innovative

healthcare experiences to more patients
For over 30 years, IBA has collaborated with leading institutions to deliver
peak proton therapy performance that enhances and saves patient’s lives.

Our continuing mission is to make proton therapy accessible to all patients

who could benefit from it. That is why we continue to develop innovative
approaches that advance the precision and efficiency of proton therapy.

PROTEUS® class is the proton therapy platform of the future offering a

comprehensive set of tools for motion management, a demonstrated spot-
scanning proton arc therapy irradiation, and finally, an ultra high-dose rate
capability for flash research.

1. Arc therapy is work in progress and Flash therapy is currently under research. Both are not available for sale.

IBA | 2000 Edmund Halley Drive, Suite 210 | Reston, VA 90191 | 571.449.4992 | www.iba-worldwide.com
 Latest And Greatest
py, delivering the beam continuously as the
gantry is rotating.
“In classic proton therapy you deliver
the beam from two to up to four angles,”
Genin said. “Arc proton therapy has three
advantages. It improves the throughput of
the facility, simplifies the treatment work-
flow and has the potential to improve clinical
outcomes for specific cases.”
The company has also successfully dem-
onstrated that its ProteusONE and ProteusP-
LUS are able to deliver Flash irradiation,
which delivers high doses of protons at ultra-
high speeds in less than one second, poten-
ProTom Radiance 330 Treatment Room
tially reducing toxicity in healthy tissue. The
company has launched an advisory board to
chael Tajima, senior director of marketing tion we have developed accessible to any
help with adoption.
at Mevion. oncological center that offers radiotherapy,”
“There’s a lot of research to be done and
The company is also launching a new said P-Cure Chief Executive Officer Michael
IBA is committed to fill that gap,” Genin said.
ceiling-mounted cone beam CT, which is Marash. “This will eventually enable every
now clinically available in Europe and soon cancer patient to obtain the best treatment
Mevion
to be FDA approved, developed by the com- in the field.”
Since last year, two proton therapy centers
pany medPhoton, and it is going to be in- P-Cure’s system is in use at the North-
with Mevion HYPERSCAN technology have
stalling a new Siemens CT on rails at Barnes- western Medical Chicago Proton Center. The
come online clinically — the University of
Jewish Hospital in St. Louis. company is supplying its system to medical
Oklahoma Stephenson Cancer Center and
For patient positioning, the company is centers in the U.K. and China, and is nego-
Maastro, formerly the ZON Proton Therapy
integrating the C-RAD Catalyst system for tiating with other cancer treatment centers
Centre at Maastro Clinic, in the Netherlands.
both surface tracking and gating. It is also and research institutes in Israel and around
The company worked with RaySearch
working to validate three new couch tops the world.
on new RayStation capabilities to enhance
and launch them this year.
Adaptive Aperture.
“Now it can shape apertures at any en-
“We’re excited to be providing a suite of ProTom International
new (image-guided radiation therapy) solu- ProTom International has been working with
ergy level with more conformality,” said Mi-
tions,” Tajima said. “We’re really trying to its proton therapy partners to make updates
leverage the best in the field.” to its products.
“You’re always looking at ways you
Mevion HYPERSCAN
P-Cure can improve your product,” said Stephen
In July 2019, proton therapy company P- Spotts, chief executive officer of ProTom
Cure, which markets a gantry-less solution International. “A lot of what we work on is
that reduces the installation costs of a proton behind the walls, so to speak.”
therapy center, announced that it had com- At an installation at Massachusetts Gen-
pleted a $15 million series B funding round eral Hospital, where patient treatment is
led by Hong Kong-based Popular Line Medi starting soon, the company is working on a
cal Group Limited. new workflow-driven user interface that is
The financing will help expand P-Cure’s fully integrated into the facility’s own oncol-
development center and production capac- ogy information system called WhiteBoard.
ity in Israel, according to the company. The The center will also have a fully integrated
company plans to establish a training and couch-mounted cone beam CT with an au-
services center for doctors, physicists, and tomatic patient positioner.
technicians in its new research and develop- “With the cone beam CT mounted on
ment center in Shilat. couch and robotic patient positioner you’re
“Completion of the financing round will not moving the patient from the imaging to
enable us to make the smart medical solu- treatment position,” Spotts said.

46 HealthCare Business News I september 2019 www.dotmed.com/news

 The company is also moving forward with
a new center, the Australian Bragg Centre for
Proton Therapy in Adelaide, where there will
be a new gantry design.
“We decided some while ago, because of
our beam line and what we wanted to accom-
plish with our system, we needed to design
our own proprietary gantry,” Spotts said. “The
new gantry design dramatically reduces the reli-
ance on the building accuracy. Things are never
perfect. The floor is never completely flat. This
design is built so that the reliance on the ac-
curacy of the building is as close to zero as pos-
sible. The gantry that we have used in the past
is wall-mounted. There are in-bed plates built
into the building. This will be sitting on the floor
with pedestals that are completely adjustable.”
The company is also working on updat-
ing its scanning nozzle to give it a larger field
of view and treatment volume, with a less
intrusive nozzle design.
The CyberKnife VOLO optimizer simplifies
the process of creating treatment plans for
the radiation therapy system using a new op-
timization algorithm, reducing both planning
and delivery time, and increasing plan quality.
“The algorithm calculates treatment
plans very quickly while also considering how
the robot more efficiently navigates to deliver
the required dose,” said Corey Lawson, vice
president of product strategy at Accuray.
Lawson said clinicians are experiencing up
to a 90 percent reduction in planning time
and up to 50 percent faster delivery time.
Hitachi_4_78-7_190807.pdf 1 8/9/19
“CMS is now reimbursing based on value
of care,” Lawson said. “If you can treat a pa-
tient with fewer fractions while improving the
quality of treatment … that is a winning com-
bination in this new healthcare environment.”
Accuray also launched the Synchrony
motion tracking and correction technology
for the Radixact system.
“It allows you to efficiently keep beam
on at all times, targeting the tumor through-
out its full range of motion. This allows cli-
nicians to also tighten margins around the
tumor, which results in the sparing of normal,
9:58 AM

Varian
In October, Varian introduced its ProBeam
360° proton therapy system. With a 30 per-
cent smaller footprint than the previous sys-
tem, the system increases the affordability of
proton therapy by reducing vault construc-
tion costs by approximately 25 percent and
cutting the construction time to 10 months C

from about two years, said Chris Toth, presi- M

dent of Varian’s Oncology Systems business. Y

The ProBeam 360° system also provides CM

customers with a pathway to potential MY

future treatment advancements, such as CY

Flash therapy.
CMY

“We look at this as a 2020 way of how

K

we personalize every radiation therapy treat-

ment,” Toth said. “What we may have un-
locked is therapy that can kill the cancerous
tissue and miss the healthy tissue. It could
mean a completely noninvasive treatment.
There is a lot of work to do to go from pre-
clinical to clinical, but we have not seen an
innovation like this in a lifetime.”

Radiation therapy
Accuray
Accuray has continued to refine the treat-
ment planning optimizer for the CyberKnife
robotic radiation therapy system.

HealthCare Business News I september 2019 47

 Latest And Greatest
Varian ProBeam 360
healthy tissue from radiation,” Lawson said,
noting that it is a technology unique to Ac-
curay.
“It requires high-speed collimation,”
Lawson said. The collimation system is able
to quickly adjust the beam to keep pace with
rapidly moving tumors like those in the lung,
liver, or pancreas. Others in the industry are
not capable of keeping up with a rapid res-
piration rate. This is very unique to Accuray.”
Phantom studies have been conducted
at the University of Wisconsin-Madison. The
technology has been installed at a second
customer site, Froedtert & the Medical Col-
lege of Wisconsin, which plans to treat the
first patient using Synchrony with Radixact in
the very near future.
The company plans on broadly rolling out
the technology at the end of the year.
Brainlab
At ASTRO, Brainlab will be showcasing a
new version of its ExacTrac Patient Position
Monitoring system. Called ExacTrac Dynam-
ic, it is a solution for precision radiotherapy
positioning and monitoring that can accom-
modate a wide range of linacs and clinical
workflows. It is not yet FDA cleared.
“Customers are currently buying two or
three different systems for patient monitor-
ing,” said Patrick Murphy, director of the
oncology portfolio at Brainlab. “Now you
can have one system for cranial radiosurgery
48 HealthCare Business News I april 2019
that includes surface tracking technology
for a wide range of radiotherapy indications.
ExacTrac Dynamic uses surface tracking to-
gether with thermal imaging, making sur-
face tracking much more robust, and com-
bines it with integrated X-Ray imaging at any
couch position during treatment.”
Clinicians can enable more precision by
integrating ExacTrac with the Brainlab Ele-
ments treatment planning software, Murphy
said.
“By using our Elements software togeth-
er with ExacTrac, we can potentially treat
with much smaller margins, because we’re
monitoring the patient so closely during
treatment,” Murphy said. “Our customers
Accuray CyberKnife VOLO
Optimizer Conformal Lung
know that by using ExacTrac they can confi-
dently monitor their patients using sub mil-
limetric precision under 1 millimeter, at any
couch position, even while the beam is on.”
Earlier this year, the company released an
update to its Elements Multiple Brain Mets
SRS treatment planning software, which has
already been used to treat more than 3,000
patients worldwide using the single isocen-
ter technique. Algorithms that are part of
the software are designed to guarantee tar-
get coverage and minimize dose to healthy
tissue, regardless of user experience. The
company also integrated its Monte Carlo
dose calculation algorithm into the software.
Another indication-specific software
module for treatment planning, Elements
Cranial SRS, was also updated to allow for
consistent and rapid volumetric modulated
arc therapy (VMAT) plan generation.
“In particular, our Cranial SRS software
has the option to limit modulation and com-
plexity of treatment, rapidly generating plans
that are more efficient, and that are faster
and easier to deliver,” Murphy said. “It auto-
matically selects the table and gantry angles
using a 4-Pi arc angle optimization”
Brainlab Elements Spine SRS was also
updated. It utilizes unique algorithms de-
veloped for spine curvature correction that
distinguish soft tissue from bony anatomy,
and for automated Clinical Target Volume
(CTV) definition, automatically applying In-
ternational Spine Radiosurgery Consortium
www.dotmed.com/news
Welcome to a new era in oncology

It’s been said that the next wave of progress in oncology

will come from an increased ability to harness the power
of technology—collecting and analyzing data to enable better,
faster decision-making in clinical care and business processes.

That next wave is here. We call it Intelligent Cancer Care™.

Learn more at varian.com/intelligent

and at ASTRO 2019 Booth #1405.

© 2019 Varian Medical Systems, Inc. Varian is a registered trademark, and

Intelligent Cancer Care is a trademark of Varian Medical Systems, Inc.
 Latest And Greatest

RaySearch
RaySearch
The company is building RayCommand
on its RayStation treat-
ment planning system
and RayCare oncology
information system with a
treatment control system
called RayCommand.
The new system is de-
Brainlab Elements signed to link RayStation
Spine SRS and RayCare and coordi-
nate activities in and be-
tween treatment rooms
consensus guidelines for spine radiosurgery that make it easier to to maximize resource
contour consistently and avoid potential errors during plan creation. utilization and treatment
accuracy. The product is about two years from being released, said
Elekta Bjorn Hårdemark, deputy chief executive officer of RaySearch.
In December 2018, Elekta received FDA 510(k) clearance for its Elekta RayCommand will also lead the way for online adaptive radiation
Unity MR-linac, a high-field magnetic resonance radiation therapy treatments, Hårdemark said.
system, which allows clinicians to see and track soft tissue during “Clinical practice today is to make a plan for the way a patient
radiotherapy treatment. looks several days before the first day of treatment, and deliver that
On the software side, Elekta will also showcase its MOSAIQ Plaza, same plan over several weeks. To deal with patient and tumor chang-
a “formal ecosystem of applications” built around its MOSAIQ on- es, oncologists use margins,” Hårdemark said. “The most modern
cology information system, and that works seamlessly with Elekta’s way to deal with anatomical changes it is online adaptive therapy. We
radiotherapy solutions, said Sukhveer Singh, president of oncology have the software technology to achieve this, but we haven’t connect-
informatics solutions at Elekta. ed that to any treatment room yet. With RayCommand, we could.”
RayCommand would also be vendor neutral.
Elekta MOSAIQ “Varian and Elekta and ViewRay are also working in that direc-
Plaza tion for their respective systems, but we can do it for any system,”
Hårdemark said.
In December of 2018, the company added two machine learning
systems to RayStation. One is used for patient segmentation. In the
U.S., the company was FDA-cleared for using machine learning to
define where the healthy organs are. In other markets, the technol-
ogy was cleared to find where the tumor is.
Machine learning is also Varian Bravos
used for planning. afterloader
“It learns from previous system

MOSAIQ Plaza includes Elekta’s own SmartClinic, which enables examples what a dose distri-
process visualization and automated, streamlined care coordination, bution looks like for particular
and Care Collaboration, which supports tumor boards and multidis- patients,” Hårdemark said.
ciplinary meetings with cross-specialty data visualization; Monaco
HD treatment planning software; IBM Watson for Oncology, which Varian
provides data-driven decision support; and voice automation using In October 2018, Varian un-
Palabra’s voice recognition technology and customizable templates veiled its Bravos afterloader
for patient notes. system for brachytherapy
“The traditional EMRs are designed to be transactional while the treatments, which delivers
value-based oncology needs more evidence-driven and workflow- radiation via tiny radioactive
oriented solutions,” Singh said. “MOSAIQ Plaza enables value-based source placed directly into
oncology with a portfolio of apps that seamlessly integrate with the tumor. The new device
MOSAIQ as the single source of truth.” improves workflow with a

50 HealthCare Business News I september 2019 www.dotmed.com/news

 Zap-X

ViewRay
MRIdian Linac

touchscreen that includes patient and treatment information and a
customizable pre-treatment checklist, and LED lights to guide clinicians
through the correct connection process of the transfer guide tubes.
“They ensure the right dose is given at the right place, at the right
time,” said Chris Toth, president of Varian’s Oncology Systems business.
In April, the company announced it was forming the Adaptive
Intelligence Consortium to research and move forward AI-driven
multimodality adaptive radiotherapy treatments.
Also this year, Varian acquired Cancer Treatment Services Inter-
national.
The acquisition includes the American Oncology Institute in Hy-
derabad and 10 multidisciplinary cancer centers across India as well
as a U.S.-based Oncology Solutions division that provides cancer care
professional services to healthcare providers worldwide.
“It gives the company unique access to global cancer data,” Toth
said.
for the first time to treat patients at Barrow Brain and Spine in Phoe-
nix. A second installation in Beijing is almost complete. The company
is close to applying for a CE mark.
The Zap-X platform has a self-shielding technology, which makes
a costly cement radiation vault unnecessary, as well as real-time
dosimetry.
“One of the ZAP-X’s major attributes is that it allows us to site
radiosurgery where the patients are, such as ambulatory surgery
centers,” said John Adler, chief executive officer of Zap Surgical.
“The idea is to take radiosurgery out of the basement and make it
much more available in the world today. Radiosurgery requires what
is arguably the most complex tech in all of healthcare. We are trying
to remedy that by making a simpler-to-use machine, which at the
same time, is also safer.”
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ViewRay
In February 2019, ViewRay received FDA 510(k) clearance to market
the new soft tissue visualization capabilities for its MRIdian Linac sys-
tem, which combines a linear accelerator with an MR scanner, was
cleared by the FDA in February 2017, and has treated approximately
5,000 patients.
Called SmartVISION, the technology doubles the frame rate of the
MR from four frames per second to 8 frames per second.
“Essentially what this does is it gives you better tracking capa-
bilities and more disease-specific imaging capabilities,” said Michael
Saracen, vice president of clinical marketing at ViewRay.
There is also expanded high-definition visualization and enhanced
contrast between different tissues, to assist clinicians with tissue visualiza-
tion and beam contouring, a diffusion-weighted imaging feature that
tracks treatment progress by distinguishing between tumor and normal
tissues, and enhanced MLC speed to potentially reduce treatment time.
“The SmartVISION helps [clinicians] to do what they are doing,
better,” Saracen said.

Zap Surgical
The company received FDA clearance in October 2017 for its Zap-X
stereotactic radiosurgery system. In January of this year it was used

HealthCare Business News I september 2019 51

 Optimized Imaging
CT dose
How much is just enough?
By John R. Fischer
Ten years ago, radiologists and medi-
cal imaging stakeholders received an
alarming wake up call. A report issued by
the National Council of Radiation Protection
and Measurements (NCRP) revealed that the
radiation exposure to the U.S. population
from medical procedures had risen dramati-
cally over the span of a few decades.
This concern around radiation dose
marked a turning point for the medical im-
aging industry, paving the way for accredita-
tion programs and official dose committees,
as well as the maturation of dose technolo-
gies and, more broadly, a greater awareness
of dose exposure. New initiatives pushed for
52 HealthCare Business News I september 2019
more discretion when choosing diagnostic
imaging exams and ensuring providers were
adequately equipped to determine, deliver
and monitor the exposure of their patients.
A prime example is the ACR Dose Index
Registry (DIR), which many providers rely on
to compare their CT dose data to their peers
locally and nationally. Since 2011, the pro-
gram has amassed nearly 2,200 facilities as
active participants and contains data from
more than 81 million CT scans.
“The information provided helps facilities
to examine and review their CT protocols,
and where necessary, cut down and opti-
mize their techniques for improving their CT
imaging,” Dr. Mahadevappa Mahesh,
ACR Medical Physics Commission chair and
chief physicist for Johns Hopkins Hospital,
told HCB News. “Also, the ACR-DIR data are
facilitating to set national or regional diag-
nostic reference levels for a variety of CT ex-
ams. Recently efforts are underway to roll out
a dose index registry for fluoroscopy exams.”
But dose registries and improvements to
technology don’t resolve radiation exposure
issues unless providers act on them. That
means taking up the mission of ensuring
patients receive the right types of exams
with just enough dose to obtain a reliable
diagnostic image.
www.dotmed.com/news
 Optimized Imaging
Vino
Durairaj
Dr. Mahadevappa
Mahesh
Dose vs. image quality
One way radiologists are getting quality im-
ages with lower dose exposure is through
iterative reconstruction, a type of software
algorithm that collects noisy data produced
by low-dose scans and reconstructs it into an
image with improved quality. The arrival
of artificial intelligence, machine learning
and especially deep learning, have all raised
the bar on what’s possible with iterative re-
construction.
“Deep learning brings the right tool for
using bigger data," said Dr. Ge Wang, a
chair professor of biomedical engineering
at Rensselaer Polytechnic Institute. “It can
reconstruct high-quality CT images from
very noisy data. Multiple papers have been
54 HealthCare Business News I september 2019
Gregg
Daversa
Dr. Ge Wang
published on the subject with excellent re-
sults. Low-dose CT reconstruction can be
done now with a deep neural network. This
is really a cutting-edge development with
real-world utilities.”
As a result, more CT manufacturers are
integrating these tools into their scanners.
Other dose management technologies long
in use, such as dose modulation, which en-
ables the scanner to adjust radiation dose
based on factors such as the patient’s size
and heartbeat, are also maturing due to
new capabilities.
“The biggest challenge for imaging pro-
fessionals is to be well-trained on the equip-
ment and keeping up-to-date with techno-
logical advancements, to maximize patient
safety and image quality,” said Vino Durai-
raj Ph.D., DABR, regional vice president of
technical operations at West Physics. “That,
I think, is where most imaging facilities are
facing a challenge.”
The right dose for the right
patient
Ten or twenty years ago, protocols for
a head CT or a chest CT would be the
same for all types of patients. Now, it is
possible to tailor dose based on patient
size. “Technologies such as dose modu-
lation, along with awareness, are help-
ing to customize dose on an individual
level,” said Mahesh.
Specific factors to consider depend on
the scan, with common ones including
age, body size and weight. Cases involving
pediatric patients especially should take
these factors into consideration, according
to Durairaj.
“If a pediatric patient has an adult-sized
body part and you’re using pediatric imag-
ing protocols you would normally use, then
the image quality is going to be compro-
mised,” he said. “In that case, we are not
providing the patient care required for that
particular patient.”
The ACR’s CT Accreditation program
not only raises awareness about dose
protocols, but ensures that sites imple-
ment them for lower and appropriate
dose levels. Using the knowledge they
gain from these programs, facilities are
examining and adjusting their imaging
protocols to meet industry standards,
which has led to a downward trend in ra-
diation dose. Also helping are campaigns
such as Image Wisely and Image Gently,
which provide information about dose
and certification.
“A lot of participants take an Image
Wisely pledge,” said Durairaj. “The par-
ticipants display pledge certificates in the
imaging department so when patients
walk in, they feel welcomed and say, ‘Okay,
the imaging professionals that are scan-
ning me today are conscious in dose reduc-
tion strategies and dedicated to following
patient safety initiatives.’”
www.dotmed.com/news
 Administering CT dose responsibly is a
team effort that requires different stake-
holders within the imaging process to have
a voice. According to Gregg Daversa,
vice president of business development for
West Physics, one of the keys to establish-
ing a culture of dose optimization is for-
malizing an official dose committee that
meets on a regular basis.
“An ideal CT dose committee would
involve a radiologist, a medical physi-
cist, a lead CT technologist, and a busi-
ness administrator,” he said. “When you
get these four stakeholders at the table is
when the core team comes together to
take the data they’ve been working with
and implement changes to optimize dose
and image quality.”
is certainly a gap between facilities that try
to achieve compliance versus those that go
above and beyond all optimization fronts
put forth by the regulatory and accredita-
tion bodies.”
At the same time, vendors are also help-
ing to ensure patients receive optimized
doses by taking into account protocols,
regulations and needs around CT dose in
the technologies they develop. As itera-
tive reconstruction and machine learning
techniques continue to complement each
other, some experts are hopeful that a new
era of patient safety and dose optimization
could be on the horizon.
“There are so many new, exciting, out-
of-the-box technologies coming out in
areas such as natural language program-
ming, neural networks and quantum com-
puting,” said Wang. “They all may turn out
to be very important, so it’s very hard at this
point to predict the future.”
Share this story: dotmed.com/news/48324

New challenges and new hopes

Patients are becoming increasingly aware
of the risks involved in radiation exposure,

Injector Support
and misinformation is a fact of life for
many people researching imaging exams

& Service
online. This creates a unique challenge for
providers, who are tasked with articulating
relative pros and cons, as well as sharing
facility details concerning accredited and
quality control programs.
“At the radiation dose levels used for
routine medical imaging such as CT, there
is no good evidence to demonstrate ad-
verse effects,” said Mahesh. “However,
there is confusion about this and depend- Providing professional,
ing on who spins the story, people are timely and superior
often really concerned even with routine
medical imaging.”
support and service
Mahesh is currently involved in a follow- for medical
up to the 2009 NCRP report which is called contrast injectors.
Medical Radiation Exposure of Patients in
the United States, and is expected to be
released in November. The report should
give an indication as to whether or not ef-
forts to reduce dose have had a substantial injectorsupport.com
impact in the last 10 years. 888.667.1062
“From my experience, most imaging
facilities attempt to meet the compliance
of regulatory and accreditation bodies
implementing the standards, whereas oth-
ers strive to reach a balance between dose
and image quality,” said Durairaj. “There

HealthCare Business News I september 2019 55

 Dual Energy
Spectral CT — Value, use
cases and implementation
By Dr. Nakul Gupta
Computed Tomography (CT) has trans-
formed medical care worldwide since
its development in the 1970s, and the
technology has advanced considerably
since then, allowing for an ever increas-
ing number of applications. CT utilizes
a rotating X-ray tube detector array in or-
der to generate cross-sectional images of
the body, typically utilizing an X-ray beam
covering a broad energy range, but with a
peak energy of 120 kilo-electron volts (120
kVp), although this may be higher or lower
in certain clinical situations. The image cre-
ated assigns grayscale values based on the
attenuation of the beam (i.e., how much
was absorbed or scattered in the patient).
56 HealthCare Business News I september 2019
While traditional CT is performed using a
single peak energy level, spectral (or “dual
energy”) CT refers to methods that obtain
information regarding tissue attenuation at
2 or more energy levels. Broadly speaking,
this may be achieved by either varying the
energy level of the beam generated by the
X-ray tube, or by discriminating between the
energies of the incident X- photons at the
detector. This allows for multiple new types
of images to be generated and multiple new
applications.
Material density images
Iodine has been employed for many decades
as a means to generate contrast in X-ray-
Houston Methodist
based imaging modalities, including CT. One
of the primary advantages of spectral CT is
that it allows separation of the total attenu-
ation of the tissue into that which is attribut-
able to iodine, and that which is attributable
to water (the primary constituent of biologi-
cal tissues) through a process called material
decomposition. This allows quantification
of iodine content, and generation of iodine
overlays or iodine basis images.
Iodine quantification is an active area
of research as a quantitative imaging bio-
marker, and is being studied as an indicator
of treatment response in various cancers,
for example. Additionally, there is a growing
body of evidence that iodine images can
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 Dual Energy
help discriminate between benign and po-
tentially malignant incidental renal masses
on routine abdominal contrast enhanced
CT’s — a common occurrence. Typically,
these incidental findings would require
bringing the patient back for a follow up
multiphase scan with and without contrast.
With iodine images it is now possible to
characterize the majority of these lesions at
the initial scan, saving time, cost, and radia-
tion dose to the patient.
Another area where material decomposi-
tion is poised to bring value to CT is in bone
marrow edema imaging. In this case, calcium
Spectral CT allows separation of the total attenua-
tion of the tissue into that which is attributable
to iodine, and that which is attributable to water
(the primary constituent of biological tissues)
through a process called material decomposition.
This allows quantification of iodine content, and
generation of iodine overlays or iodine basis images.
is used as one of the basis materials, and by
removing its contribution to the image, it
becomes possible to visualize bone marrow
edema, which could previously only be done
with MRI. Although research is ongoing and
this is still in its infancy, many centers are be-
ginning to employ it in the clinical routine.
These are typically performed in the trauma
setting, such as when evaluating spinal com-
pression fractures. Currently, determining the
acuity of spinal compression fractures at CT
can be unreliable, and many patients go on
to have an MR, resulting in additional cost
and possibly length of stay. With spectral CT,
it may be possible to answer this question up
front, reducing both cost and length of stay.
Virtual unenhanced (aka “virtual
non-contrast”) imaging
Many scan protocols call for an initial
58 HealthCare Business News I september 2019
non-contrast scan followed by a contrast-
enhanced scan. This allows the radiologist
to differentiate between tissues that were
intrinsically bright on the image prior to con-
trast administration from those which be-
came bright only after contrast administra-
tion. However, this comes at extra expense,
time, and radiation dose to the patient.
With spectral CT, once the iodine and wa-
ter contributions have been decomposed,
virtual unenhanced images can be gener-
ated which mimic a non-contrast scan. In
some applications this virtual unenhanced
image may be able to replace an actual non-
contrast scan in multiphase pre- and post-
contrast protocols, saving time, radiation
dose and cost.
Virtual monoenergetic imaging
X-ray beams consist of individual photons of
varying energy, although with a user selected
peak energy level (i.e. 120 kVp). This is re-
ferred to as a polyenergetic or polychromatic
beam. The image generated is therefore a
composite of all of the different energy X-ray
photons contained in the beam. Spectral CT
allows the generation of virtual monoener-
getic images, as if the beam consisted entire-
ly of a single X-ray energy. This can benefit
in several ways.
Lower energy images can be generated
that enhance the appearance of iodinated
contrast. These have been shown in multi-
ple studies to improve lesion conspicuity in
the liver, both for hypervascular and hypo-
vascular masses. Additionally, they can be
used in angiography to enhance vascular
contrast. This can be leveraged to reduce
contrast dose, which can both reduce cost
as well as improve patient safety (lower
risk of contrast induced nephropathy), and
can also reduce the need for repeat scans
due to a suboptimal contrast bolus. CT pul-
monary angiography occasionally suffers
from transient contrast interruption which
can result in a non-diagnostic scan, for ex-
ample. In these cases patients are often
re-dosed with contrast and rescanned, re-
sulting in both double the contrast load as
well as double the radiation dose. With vir-
tual monoenergetic imaging, lower energy
images can be reconstructed that enhance
what contrast there is and can salvage an
otherwise non-diagnostic scan, reducing
cost as well as contrast and radiation dose
to the patient.
On the other hand, higher energy images
can be generated which reduce metal arti-
fact, such as in the presence of orthopedic
hardware. This is of significant benefit in the
evaluation of joint prostheses, where tradi-
tional CT scans suffer from severe artifacts.
The difference is so dramatic, in fact, that
in our own institution, many orthopedists
now specifically request scans to be done
with dual energy. We also use higher energy
virtual monoenergetic images in addition
to metal artifact reduction to improve CT
myelography in the presence of spinal hard-
ware, and have not looked back.
Niche applications
In addition to the broader applications de-
scribed above, there are several niche ap-
plications to be aware of. For one, spectral
CT allows characterization of kidney stone
composition, which can affect how they may
respond to various treatments. This can be
valuable information to the urologist, and
allow for more expeditious triage to the cor-
rect treatment. Additionally, through simi-
lar techniques, spectral CT can be used to
detect gout tophi. In fact, spectral CT is al-
ready included as a criterion for establishing
a diagnosis of gout, and can also be used to
monitor patients who are on therapy.
www.dotmed.com/news
Training and workflow
considerations
As with any new technology, its value will
not be realized without adequate staff
training. Luckily, there is little difference
from the technologist’s perspective be-
tween scanning a single energy or dual
energy scan on the latest systems. In fact,
most systems also allow generation of at
least some basic spectral reconstructions
at the scanner console itself, in automated
or semi-automated fashion, which can
then be pushed to PACS for review. This
avoids the need for the technologist and/
or the radiologist to have to use a sepa-
rate workstation or thin client, saving valu-
able time and minimizing interruption of
the standard routine. The more important
task is deciding when and where to lever-
age the capabilities of spectral CT without
overwhelming the radiologist with a sea of
images. This requires careful attention to
protocol design, as well as radiologist edu-
cation regarding the new types of images
and their use. To this end, there are many
workshops and conferences available for
this purpose. While it may not be possible
for every radiologist to attend, at least a
handful of radiologist “champions” should
be designated who can take the lead. One
of the major concerns from radiologists is
the increasing number of images to review.
What we have found helpful to encour-
age adoption in this regard is to begin by
introducing virtual monoenergetic images,
since these have the “look and feel” of
traditional CT images, but with the advan-
tages discussed above. In many cases these
can replace the routine image set, resulting
in a net-neutral image count.
In summary, there are many ways
in which spectral CT can benefit clinical
practice and enhance value, whether by
unlocking novel CT applications, reduc-
HealthCare Business News
ing contrast dose, or reducing radiation
dose by eliminating certain non-contrast
exams or repeat scans. While the plethora
of available images may seem overwhelm-
ing at first, taking a stepwise approach to
implementation and designating a handful
of radiologist champions can help make for
a smooth transition.
About the author: Dr.
Gupta is an Assistant
Professor of Radiol-
ogy and Director of
Body MRI at Houston
Methodist Hospital
with fellowship
training in body cross
sectional imaging. His academic interests
include dual energy/spectral CT, as well as
advanced body MRI applications.
Share this story: dotmed.com/news/48325
I september 2019 59
 Ultrahigh-Res CT
If you’re a regular reader of HealthCare
Business News magazine, the name
John Boone might be familiar to you. A
couple of years ago we sat down with him
to talk about a novel breast scanning CT sys-
tem he developed alongside colleagues at
UC Davis. We recently reached out to him
again to discuss another CT innovation —
ultrahigh-resolution.
Boone is a researcher, educator, and
clinical medical physicist with long-stand-
ing interests in CT technology. He is former
president of the American Association of
Physicists in Medicine (AAPM), and cur-
rently chairs the CT subcommittee for this
organization. He is also the primary author
of the ICRU (International Commission on
Radiation Units) Report 87, “Patient dose
and image quality assessment in computed
tomography”.
HCB News: In April, UC Davis Health
announced that it was performing clini-
cal imaging exams using an ultrahigh-
res CT scanner. Can you tell us a bit
about the technology and how it came
to be acquired by the facility?
John Boone: About 2 years ago, I was
approached by an executive from (then)
Toshiba, about the potential of siting this
new high-resolution CT scanner at UC Da-
vis. I was immediately excited about the
prospect of evaluating this new technology
— and as a leader in the research adminis-
tration of my academic radiology depart-
60 HealthCare Business News I september 2019
Q&A with
John Boone
professor of radiology and biomedical
engineering, and chief of medical physics
University of California Davis
Ultrahigh-res scanning comes to CT
By Gus Iversen
ment, I saw the opportunity for my young
academic radiologist colleagues to have an
opportunity to evaluate and report on this
technology in a series of clinical protocols
spanning applications from neuroradiology
to musculoskeletal radiology — and that
was the primary motivating factor for me
in this project.
This CT scanner (which is now the Can-
on Aquilion Precision) has high-resolution
features, which, in my opinion as a medi-
cal physicist specialized in CT technology
are a game changer for CT imaging — per-
haps not for every CT examination, but for
a number of imaging applications I believe
the high-resolution capabilities will lead to
more accurate diagnoses and better patient
care. The system has a 40 mm-wide detector
(measured at the isocenter, per industry stan-
dards), with 160 – 0.25 mm wide detector
arrays along the long axis of the scanner (the
Z dimension). There are 4 different acquisi-
tion modes, which the manufacturer refers
to as normal resolution, high resolution, su-
per high-resolution, and ultrahigh-resolution
modes. Of course, the size of the detector
elements is not the only resolution-limiting
factor, and this scanner has 7 different focal
spot sizes that can be used, unlike any whole-
body clinical CT scanner I have seen in the
past. Obviously, the smaller focal spots need
to be used with the higher resolution detec-
tor modes to actually achieve high-resolution
images. The system is capable of reconstruct-
ing images with 0.15 mm pixel dimensions,
with imaging matrices of 512 x 512, 1024 x
1024, and 2048 x 2048. The MTF, which is
the traditional measure of spatial resolution
in imaging systems, has a limiting resolution
for clinical operation on the order of 3.2 pairs
per millimeter, which is consistent with the
150 µm voxel dimensions.
HCB News: What does ultrahigh-res
mean in terms of CT scan image quality?
Does it open up new capabilities?
JB: We are all aware of the various mo-
dalities available in the radiology department
for imaging patients and, of course, each of
these modalities has its strengths and weak-
nesses. Traditional resolution CT imaging
excels at contrast resolution (the ability to
see large lesions with subtle contrast differ-
ences) but is not particularly exciting when it
comes to spatial resolution (the ability to see
small objects) — which for most clinical CT
scanners the smallest resolvable element is
on the order of 0.50 mm. But with this new
CT scanner, we have the ability to resolve
0.15 mm voxels; and the obvious question is,
“What human anatomy has spatial features
on the scale from 0.15 to 0.5 mm?” The
answer to this is the answer to your question
about “new capabilities”. We believe that
the increase in spatial resolution achievable
by this new CT scanner technology will al-
low meaningful improvement in diagnoses
involving lung parenchyma, the anatomy
of trabecular bone (in trauma and disease),
liver texture, and microvasculature — the
www.dotmed.com/news

latter of which includes diagnoses related to
cancer, vascular disease, and a whole host
of other pathologies. Thus, the prospective
capabilities of this scanner are exciting to
me, and through clinical trials we are trying
to methodically evaluate which specific areas
of CT imaging this new device will advance.
HCB News: Can you provide any ex-
amples of how those exceptional im-
ages have impacted diagnostics for your
patients?
JB: Your readers will recognize that as
the voxel dimensions of the CT image get
smaller, the spatial resolution increases, but
so does the quantum noise. At the same
radiation dose levels, fewer X-ray photons
traverse a smaller voxel relative to a larger
voxel, so consequently, there will be larg-
er quantum noise levels when the smaller
voxels are reconstructed. When the Canon
scientists presented this technology to me
and a group of other medical imaging sci-
entists, of course this was the first question
that came to mind. Initially the solution to
decrease quantum noise with the high-res-
olution images was dealt with using itera-
tive reconstruction techniques, which have
become the industry standard method for
noise suppression in CT over the past de-
cade. I was frankly impressed to find that
this manufacturer has also developed CT
reconstruction methods designed to reduce
noise based upon artificial intelligence tech-
niques — their deep learning reconstruction
algorithm. I’m very excited to see how the
DLR algorithm reduces noise in the high-
resolution images, however this software
was only recently FDA approved and is about
to be installed on our scanner in the next
week or two. For many applications, we
were waiting for the DLR algorithm in order
to fully assess the system clinically, and we
now have our sleeves rolled up to do so. So
please ask me this question in a year or so,
and I will have a better answer after we have
done the research.
HCB News: Operationally, how has
training and utilization of the system
compared with other conventional CT
scanners at UC Davis Health? Is there a
learning curve?
JB: This scanner has a large repertoire
of options, as you would imagine, and we
are still very much on the learning curve in
terms of protocol development. We have
all become used to the complexity of mod-
ern CT scanners, with automatic exposure
techniques (tube current modulation), and
all the other factors involved in CT proto-
cols. With this scanner, we add to the mix 7
different focal spot sizes, 4 different recon-
struction modes, 4 different reconstruction
algorithms (each with many flavors), and
you can begin to realize how complex this
system is. This scanner is a research scanner
to some of us, but it is FDA approved and
therefore, it is used at our institution for
clinical imaging from 7 am to 5 pm. The
standard of care imaging comprises the
bulk of our clinical investigations compar-
ing high-resolution to low-resolution CT.
We really are still at the front end of the
learning curve given the complexity of this
CT scanner, and I hope over the next few
months we will be able to focus on a num-
ber of specific clinical protocols and opti-
mize them to achieve the best compromise
between spatial resolution and noise. This
new high-resolution scanner is certainly a
game changer, but realistically it will take
a couple of years for my radiologist col-
leagues to learn how to use this new tech-
nology in order to confidently and routinely
use this tool to advance patient care.
HCB News: Can you discuss any re-
search you are currently conducting
with the use of the system?
JB: As a medical physicist, there are
many basic science studies we are plan-
ning to do, and these studies are ongoing.
We have focused our early clinical investi-
gations on areas of CT imaging where we
feel that the spatial resolution capabilities
of this new scanner will most impact pa-
tient care. Our current priorities are in lung
imaging, and I can report that our chest
radiologists give 2 thumbs up on high-res-
HealthCare Business News
Avante's new Center of Excellence
in Charlotte, NC provides 160,000
olution CT; we are also focusing on mus-
square feet for the company’s
culoskeletal imaging, and have imaged a
imaging, oncology and
number of cadaver limbs in various
ultrasound studies
divisions.
which show huge potential; we also feel
that neuroradiology applications such as
temporal bone imaging is clearly some-
thing that this scanner will provide new
diagnostic accuracy for. We have a fleet of
CT scanners at our medical center, and we
are prioritizing the use of this new scanner
for a subset of our ambulatory patients to
focus on these specific areas.
HCB News: Has anything about the
new system been a surprise?
JB: For me personally, there have been
huge surprises relating simply to the in-
stallation of the scanner. Since this inter-
view is for Healthcare Business News, I
feel compelled to mention the following:
I wear many hats, but as a clinical medical
physicist for 35 years, I have always viewed
the delays of equipment installation in the
hospital setting as result of bureaucratic
inefficiency and indecision. However, as
principal investigator of this project, I was
intimately involved with most of the steps
that were required to install the CT scan-
ner into our clinical CT area. I was so fully
impressed at how a thousand people came
together in a thousand meetings to expe-
dite the installation of this CT system. I had
no idea of the complexity of the process,
and am dumbfounded, and grateful to all
those who participated in making the sit-
ing of this CT scanner at UC Davis possible.
From the vice chancellor and CEO of the
hospital, to the many administrators, ar-
chitects, engineers, IT staff, lawyers, X-ray
technologists, and so many more that were
involved in the necessary discussions and
decisions required to install this CT scan-
ner. I have a newfound respect for all those
who have a hand in the siting of complex
imaging equipment. As a longtime la-di-da
full professor in the school of medicine, my
advice to similarly gilded colleagues around
the country is simple: hug your administra-
tors today!
Share this story: dotmed.com/news/48326
I september 2019 61
 Latest In CT
AI comes to the CT market
By Lisa Chamoff
Artificial intelligence (AI) has been a buzzword in imaging for
the last few years. Recently, in the CT market, AI has gone from
dream to reality, with several companies offering image quality en-
hancements using machine learning.
This comes along with the release of compact systems for outpa-
tient orthopedic imaging and wide-bore systems for larger patients.
Here’s a look at what’s new in CT scanners and software.
Canon AiCE 1
Canon Medical Systems
In June of this year, Canon Medical Systems received FDA clearance
for its Advanced Intelligent Clear-IQ Engine (AiCE), which uses a deep
learning algorithm to differentiate signal from noise in CT images, so
noise is suppressed while signal is enhanced.
“It makes it easier for the physician to read and have a natural tex-
ture for the image,” said Tim Nicholson, senior marketing manager
for Canon Medical Systems. “With the (previous) dose reduction, you
gave up texture. With this type of reconstruction using deep learning,
it really brings that image quality up another step and it can go a step
further in lowering the dose because there’s less noise in the image.”
AiCE is available on new purchases of Canon’s Aquilion ONE /
GENESIS Edition, released three years ago, and the Aquilion Precision
platforms, released in April 2018. The company plans to eventually
make AiCE available on new mid-tier scanners.
“We believe our deep learning reconstruction will be superb be-
cause it’s fast enough to use on every single exam,” Nicholson said.
“We have quantifiable claims we used in our FDA submission on
noise reduction and low-contrast detectability.”
Carestream
Carestream released its OnSight 3D Extremity System in February
2017. Since the release, it has added workflow improvements and
enhanced metal artifact reduction.
62 HealthCare Business News I september 2019
Carestream's
OnSight 3D
Extremity System
“We are able to handle much smaller pieces of metal and bigger
pieces of metal such as knee implants,” said David Chan, regional
business director for the U.S. and Canada for Carestream. “They can
see micro fractures or signs of infection.”
The scanner allows imaging from the distal femur to the toes with
and without weight bearing, and the distal humerus to the fingertips,
allowing surgeons to have a better image of the problem before a
procedure. The systems are designed for sports medicine facilities.
Carestream is next tackling deep learning to improve image qual-
ity as well as the validation of 3D measurements.
“Now, weight-bearing measurements are done on 2D projection
radiography,” Chan said. “We’re leveraging some of these devel-
opments into 3D measurements and validating their accuracy and
validity in a working group.”
CurveBeam
Since receiving FDA clearance for its LineUP bilateral weight-bearing
CT imaging system for the knees and lower extremities, in May 2018,
CurveBeam is developing an upgrade that will extend imaging capa-
bilities up to the hips.
“The body would be slightly modified so that the gantry could
raise higher,” said Vinti Singh, marketing manager for CurveBeam.
“The capability to scan up to the hip is essential for preoperative
planning for knee replacement surgery because the hip is a required
anatomical reference point.”
The key features of the device, including a compact footprint and
the ability to plug into a standard wall outlet, will remain.
“Research demonstrates weight-bearing CT may be instrumental
in detecting early signs of knee osteoarthritic degeneration,” Singh
www.dotmed.com/news
CurveBeam
LineUP FUJIFILM Medical Systems
U.S.A., Inc.
FUJIFILM Medical Systems U.S.A., Inc. an-
nounced its entry into the CT market at last
year’s ASTRO with its FDA-cleared FUJIFILM
FCT Embrace, which the company says is the
world’s first 64- to 128-slice scanner with an
85-centimeter bore.
“We’re new in this space but we’re not
new to digital imaging, with continued
advancements from X-ray film in 1936 to
digital radiography and AI today,” said Rick
Banner, senior director of marketing for CT,
DR and women’s health at FUJIFILM Medical
Systems U.S.A., Inc.

FUJIFILM FCT
Embrace

said. “In addition, studies show you can view

the knee meniscus better via weight-bearing
CT arthrogram than on MRI.”
The company is aiming for a 2020 release
for the hip scanner.

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HealthCare Business News I september 2019 63

 Latest In CT
The system provides a seamless transi-
tion from oncology to radiology with rapid
acquisitions of chest and gating studies and
GE Healthcare - Revolution Apex
a wide 49-centimeter table, Banner said.
The scanner comes with FUJIFILM’s Low-
dose Iterative Solution Approach (LISA) with
PixelShine, which uses advanced data-driven
algorithms to reduce image noise and mini-
mize artifacts, while maintaining or improv-
ing spatial resolution for more optimal dose
and image quality.
“I see this being a good fit for a large
academic, medium-sized hospitals and out-
patient facilities as their bread-and-butter
scanner,” Banner said.
The scanner was also built with a modu- GE Healthcare were previously reconstructed. FDA cleared
lar design, resulting in fewer parts, leading GE Healthcare has had many new releases in in April, the technology produces what GE
to easier maintenance, Banner said. For ex- the CT space over the last year, starting with calls “TrueFidelity” images that improve
ample, the brushes, which create carbon three new additions to its Revolution family noise texture while maintaining dose.
dust, have been removed, and so don’t of CT scanners. “We are very excited about the image
need to be cleaned or replaced. It also has The Revolution Apex comes with GE’s quality GE’s Deep Learning Image Recon-
a touchscreen monitor with a keyboard and new Deep Learning Image Reconstruction, struction engine has created,” said Scott
mouse as well. which uses algorithms based on images that Schubert, general manager for premium CT

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64 HealthCare Business News I september 2019 www.dotmed.com/news

at GE Healthcare surements in assessing and following up on Through GE’s Smart Subscription, cus-
The Revolution Apex also comes with a thoracic diseases, according to the company. tomers can stay up to date on the latest
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deliver both power and coverage together, fying areas that have relative deficits of per- tion model.
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ous X-ray tube in a 16-centimeter-wide cov- sues such as pulmonary embolism or chronic Hitachi
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“For the first time in the CT industry we “Before the application, the physician 2017, Hitachi is working on a new 64-128
can provide power and wide coverage,” would just have to do it quantitatively, bring slice CT in the premium market segment
Schubert said. together the CT image with perfusion image for general hospitals and their EDs, which
The company also launched new capabili- and figure out the boundaries of the lobes of fits between the economy 64-128 market
ties on its Revolution EVO Gen 2 and Revolu- the lung,” Schubert said. for imaging centers and small hospitals
tion Frontier Gen 2 systems. Revolution EVO “That was a manual and less quantitative and an ultra-premium, 64-128-slice high-
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 Latest In CT
The scanner will do cardiac, neuro-
logical shuttle, interventional and DECT
exams and is designed with innovative
features to accommodate larger bariat-
ric patients and with high workflow, said
Mark Silverman, director of CT market-
ing for Hitachi.
“This new scanner is targeted to gen-
eral hospitals for inpatient and outpatient
needs, which we feel is the largest segment
of the U.S. market,” Silverman said. “For
CT at Hitachi we don’t target the academic
buyer. We target to provide the most ver-
satile and best value proposition for the
general hospital buyer. We’re really talking
about a machine that is better in terms of
capabilities, quality and value for general
hospitals.”
The product is FDA 510(k) pending and
Hitachi plans to showcase it at this year’s
RSNA.
Hitachi Supria
“Regular CT sensors are small-tiled ar-
rays, with 600-pixel micron spacing,”
Neushul said. “Our system has a single large
area detector with pixel spacing of 140 mi-
crons.”
In 2012, the company obtained an FDA
510(k) clearance for an earlier device, the
ClarisCBCT, and iCRco is now in the process
of obtaining FDA 510(K) allowance for the
new device, which it says has a larger diag-
nostic reconstructive volume.
The ClarisXT is a lightweight, portable
CT solution that includes a workstation with
review capability, a movable gantry and
movable table, and is capable of full-field
diagnostic X-ray imaging as well as CT. It
comes with ClarityPACS and ClarityPractice
for scheduling patients, reviewing, reporting,
storage and billing.
“The ClarisXT is the result of eight years of
development, and almost 30 years of involve-
ment in the medical imaging field,” Neushul
said. “We will introduce this device into por-
table applications, orthopedic practices and
small clinics, and eventually we hope to use
it for spine surgeons and for lung nodule
screening. We are bringing CT technology to
a level that will allow traditional X-ray users to
expand their imaging capability to include 3D
imaging. ClarisXT is a low-dose, high resolu-
tion system, with a guided workflow inter-
face, simplifying the acquisition process. This
new device will provide an exciting oppor-
tunity to improve patient care at all levels.”
NeuroLogica
NeuroLogica, a healthcare subsidiary of Sam-
sung Electronics Co. Ltd., has partnered with
Winnebago Specialty Vehicles to increase
access to mobile CT clinics across the U.S.
The vehicles come equipped with Neuro-
Logica’s BodyTom Elite, a 32-slice full-body
CT scanner, which has an imaging algorithm

iCRco inc.
iCRco inc.’s latest product, the ClarisXT, is
a multi-modality device that provides high-
resolution 3D imaging, as well as full-field di-
agnostic X-ray. ClarisXT replaces a traditional
X-ray system in an orthopedic, sports medi-
cine or medical clinic. The system is designed
for general X-ray applications, orthopedic
imaging, bones and joints, as well as head
and neck studies.
ClarisXT provides four times better reso-
lution than traditional CT, at a third of the
dose, said Stephen Neushul, president, iCRco inc. Claris XT
chief executive officer and head engineer
of iCRco.

66 HealthCare Business News I september 2019 www.dotmed.com/news

 “You can drive it around the hospital,”
Neurologica BodyTom
Webster said. “If someone is in the hospital
Mobile Lung Unit
for a traumatic brain injury, you can monitor
them instead of transporting them. With
this, now the patient stays in the ICU in the
bed and they don’t have to move them.

for low-dose lung screening that was ap-
proved by the FDA in 2018.
“Winnebago Specialty Vehicles has a
long history of mobile medical care,” said
David Webster, chief executive officer of
NeuroLogica.
NeuroLogica and Winnebago Specialty
Vehicles division collaborated this summer
for the first Mobile Lung Symposium in Min-
neapolis, Minnesota, hosting speakers from
the American Lung Association, Atrium
Health’s Levine Cancer Institute and others.
The companies plan to work together to
build more mobile screening vehicles.
At RSNA 2018, NeuroLogica launched
and its 16-slice, small-bore CT scanner,
OmniTom. The mobile system can be used
at the point-of-care in the neuro-ICU and
in the operating room for neurosurgery
cases and full-body pediatrics.
Philips
At ECR in March, Philips launched its Incisive
CT, a general purpose 64-slice and 128-slice
scanner.
The 72-centimeter bore “workhorse”
scanner comes with a “Tube for Life” guar-
antee — Philips will replace the new vMRC
tube X-ray tube, which the company says is
already more reliable, throughout the entire
lifespan of the system at no additional cost.
This guarantee has the potential to re-
duce operational expenses by an estimated
$400,000.
“One of the most expensive components
in CT is changing the tube,” said Karim
Boussebaa, business leader for computed
tomography and advanced molecular im-

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 Latest In CT

to shift services to the outpatient environ-

Philips Incisive CT
aging at Philips. “The model has been to
drive revenue through services. Philips has
engaged in a different approach with our
customers, one where we want to be part-
ners. Incisive CT reflects that approach.”
The company expects the scanner to be
available in the U.S. later in the year.
“With all of the scientific and clinical
research proving the value of CCTA, it’s
now the question of, ‘Where can these
services be delivered?’” Dedman said.
“Historically, a CT scanner capable of high-
quality cardiac imaging is installed within
a hospital. We’re seeing a trend, though,
ment. That’s really where the SOMATOM
go.Top Cardiovascular Edition is going to
be implemented.”
Aside from a tablet-based workflow
that allows the technologist to stay with
the patient for a majority of the exam, the
scanner also comes at a price point that’s
suitable for an outpatient environment,
Dedman said.
At last year’s RSNA, Siemens unveiled an
artificial intelligence platform called AI-RAD
Companion, and the first application avail-
able on the new platform is for chest CT. The
AI-RAD Companion Chest CT application
is designed to mark and measure potential
abnormalities in the lungs, heart, and aorta
to assist the radiologist in their interpretation
of chest CT scans.
“The idea is to provide the radiologist
with more data-enriched images and allow
them to be more efficient and accurate in
their interpretation,” Dedman said. “The
radiology workforce is not growing at the
same pace as the exam volume. We feel a
tool like the AI-Rad Companion allows us to
offload work. We clearly see this as a com-
plement to the radiologist.”
Share this story: dotmed.com/news/48327

Siemens Healthineers
At the American College of Cardiology
annual meeting this past March, Siemens
Healthineers debuted the SOMATOM
go.Top Cardiovascular Edition, a new ver-
sion of the 128-slice CT scanner designed
with the necessary hardware and software,
as well as a workflow geared specifically to-
ward cardiac imaging.
The scanner is capable of providing the
high-quality coronary CTA (CCTA) images
required for the HeartFlow FFRCT Analysis,
a cardiac test developed by HeartFlow Inc.,
that enables clinicians to better evaluate the
impact a blockage has on blood flow and
determine the best treatment for patients,
according to the company.
Research has shown that CT for front line
coronary CT imaging has value, said Mat-
Siemens Somatom
thew Dedman, director of marketing for GoTop
CT at Siemens Healthineers North America.

68 HealthCare Business News I september 2019 www.dotmed.com/news

 Best Practices
Ten-year study finds
low-dose CT is the standard
for lung cancer screening
By John R. Fischer
The implementation of low-dose CT in lung cancer screenings
may significantly reduce mortality among high-risk individu-
als, according to the findings of a 10-year Dutch-Belgian trial.  risk individuals; acquiring consistently high-quality images from LDCT
Presented last year at the International Association for the Study
of Lung Cancer (IASLC) 19th World Conference on Lung Cancer
(WCLC) in 2018, the NELSON lung cancer screening trial argues on
behalf of LDCT as a standard for assessing risk of lung cancer devel-
opment, aligning with the findings of National Lung Screening Trial
(NLST) conducted in the U.S.
“In screening, you’re not dealing with patients with lung cancer
but people at risk for the disease,” Dr. James Mulshine, professor of
internal medicine at Rush University in Chicago and chair of the Early
Detection and Screening Committee of the IASLC, told HCB News.
“In this pre-disease setting, we want to reduce the harm of medical
radiation to as low as possible. In the last decade, the medical indus-
try has shown it can produce extraordinary, high-quality imaging at
very low dose so that the risk to this asymptomatic subject popula-
tion is quite negligible. That’s why we specify low dose in this setting.
We want to incur as little difficulty for these individuals as possible.”
A total of 1.6 million deaths occur each year due to lung cancer,
with more than 60 percent diagnosed after the cancer has metasta-
sized, leading to worse outcomes.
Started in 2002, the primary results of the NLST were released in
2011, revealing that annual exams with LDCT reduced lung cancer
mortality among high-risk patients by 20 percent and overall mortal-
ity by 7 percent compared to controls.
The findings led the United States Preventive Services Task Force
in 2013 to recommend LDCT as the standard for U.S. screenings of
high-risk individuals, who are defined as those between 55 and 80
with a smoking history greater than or equal to 30 pack-years and
who have not quit within the last 15 years.
The NELSON trial found LDCT to reduce deaths from lung can-
cer by 26 percent in high-risk men and by up to 61 percent in
high-risk women. Those with such risks were defined as current
and former smokers between 50 and 74 who smoked greater than
10 cigarettes daily for more than 30 years or more than 15 a day
for over 25 years.
Taking into account the findings of both trials, the IASLC Early De-
tection and Screening Committee affirmed its support of the use of
LDCT for significantly reducing lung cancer mortality among high-risk
individuals, prompting it to urge the adoption of screening programs
that incorporate multidisciplinary groups of experts.
It also encouraged the use of best practices for identifying high-
and incorporating radiological guidelines, including definitions for
positive versus negative results; integrating smoking cessation into
lung cancer CT screening programs; incorporating a defined process
of surgical or other diagnostic interventions for suspicious nodules;
and using a defined clinical work-up for “indeterminate nodules”
and for pathology reporting of nodules.
Mulshine says training around these methods is crucial in identi-
fying and addressing high risks of developing lung cancer early on.
“Institutions are not always used to performing low-dose CT so
they have to learn to do it and do it well, with screening,” he said.
“It’s the leading cause of death in the U.S. and the rest of the world
and we’d like to help avoid that in these tobacco-exposed individuals
who are at elevated risk of developing this disease.”
The IASLC acknowledges that implementation of LDCT screening
worldwide is up to the authority of each individual national health
service.
The 19th WCLC took place in Toronto, Canada.
Share this story: dotmed.com/news/45021
HealthCare Business News I september 2019 69
 Building Barriers
Radiation shielding — experts
share tips to get the most
value
By Lauren Dubinsky
On a day-to-day basis, radiation shield-
ing is probably not something that is
on the top of a healthcare provider’s list
of concerns, but these massive projects
are crucial to any facility. Whether it’s an
imaging department or a radiotherapy treat-
ment center, having a basic knowledge of
shielding will help you make sure the right
decisions are made when shielding projects
or issues arise. A few experts in the field
shared their insight with HCB News on these
matters.
70 HealthCare Business News I september 2019
What information should
providers share with their
shielding partners?
Shielding a diagnostic imaging facility and
shielding a radiotherapy facility are two
completely different tasks. Both require the
facility to share certain information with the
shielding company, but radiotherapy takes
things to a whole other level.
“Radiotherapy is a lot more complicated
because you’re dealing with much higher
levels of radiation,” said Cliff Miller, direc-
Photo courtesy: Veritas
Laying down
ceiling blocks
for shielding.
tor of marketing and IT at NELCO World-
wide. “If you’re above a 10 megavolts ma-
chine, you’re not just dealing with gamma
but you’re also dealing with neutrons to
shield for.”
Because of that, it’s beneficial to engage
with the company early on in the planning
phase regarding planning for the space re-
quirements, the ancillary space around the
room and fitting feasibility. All of that can
have a large impact on the budget and
schedule for completing the project.
www.dotmed.com/news
 “A radiation therapy vault may need four or eight feet of concrete
on four- or eight-foot-thick walls and that obviously takes up a lot
of room,” said Miller. “We can incorporate other materials to make
the thickness of the rooms smaller so that maybe you can fit an extra
treatment room in or fit it into a space that you didn’t think could fit
one before.”
Although shielding for the diagnostic setting is much simpler,
there still is pertinent information that needs to be relayed. An-
drew Martin, director of physics at Veritas Medical Solutions, said
that facilities should identify the brand, model and features of the
equipment they have selected, the maximum available dimensions,
any obstructions within the area or logistics to the work space, the
treatment types, dose per patient, the maximum treatment capacity
they intend to offer and their local radiation protection regulations.
Paul Rochus, business development executive at MarShield
Radiation Shielding, stressed the importance of knowing what sort
of attenuation they need as well as the lead thickness. To determine
that, they can consult with a health physicist or may have someone
on staff in their radiation safety department.
But one thing every facility should always make sure to have is a
good set of architectural drawings, according to Thomas Petrone,
chief executive officer and chief medical physicist at Petrone Associates.
“These would have been created through a good working pro-
cess between the owner, the equipment manufacturer, the technical
staff who will utilize the equipment and the medical physicist,” he
said. “The physicist must provide a good shielding requirements
analysis before the shielding company can adequately bid the job.”
In the analysis, alternative shielding materials such as normal and
high-density concrete can be considered for higher energy machines.
On the lower-end side, such as mammography, gypsum board may
sometimes be used in place of some lead.
To lead or not to lead?
For the diagnostic setting, lead is the shielding material of choice,
but is it always the best choice? NELCO’s Miller definitely thinks so
— citing that “it’s the most cost-effective, easy to install, quickest to
install, it’s flexible and gives a finished product that the customers
are happy with.”
The downside of lead is that it’s toxic and requires special manu-
facturing, handling, transportation and working restrictions. The
WHO stated that lead negatively affects the development of the brain
and nervous system in children, and may also lead to high blood pres-
sure and kidney damage in adults.
The Institute for Health Metrics and Evaluation found that lead
exposure was responsible for an estimated 540,000 deaths in 2016.
It accounted for nearly 64 percent of the global burden of idiopathic
developmental intellectual disability as well as 3 percent and 3.1
percent of the global burden of ischemic heart disease and stroke,
respectively.
A few of the shielding companies have developed products
and come up with strategies to mitigate the risk of lead exposure.
MarShield sells lead bricks so that they can be painted to enclose the
lead as well as rolling barriers, which encase lead in a metal frame.
NELCO has a comprehensive environmental health and safety
program to address all of the safety concerns that their customers
have with lead.
“We limit the amount of cutting and what we bring on to a job
site,” said Miller. “We’re not going to be cutting on a job site, be-
cause that can spread the lead throughout a building and we control
the area where the lead is being installed so no one can access it.”
Lead is less expensive than other materials, like tungsten, but it’s
still not considered to be inexpensive. To prevent waste, NELCO cuts
lead with a knife instead of a saw so there is no dust.
According to Veritas’ Martin, lead is not a structurally sound mate-
rial on its own and is subject to a phenomenon called Lead Creep. In
those cases, a structural cage will typically be required to ensure the
lead does not creep over time and collapse.
“You can use concrete instead of lead but need a much, much
greater thickness,” said Petrone. “In a new building construction and
where land is not expensive, that could be okay and is often a choice,
but in a city that becomes problematic.”
But Petrone added that the ultimate solution is to involve all stake-
holders upfront in the process. By doing that, you can minimize lead
or other shielding by working with architects and physicists to come
up with the ideal placement of the radiology equipment.
• Lead Lined Cabinets
• Radiation Barriers
• Modular Booths/Walls
• Lead Curtains
• Lead Bricks & Sheet Lead
• Borated Polyethylene
• Leaded Glass & Acrylic
• Lead Lined Storage Containers
• X-Ray Rooms Design
& Construction
• Tungsten Vials
& Syringe Shields
• Lead Pig Vials & Waste
Containers
• Design & Consultation Services
1.800.381.5335 | sales@marshield.com | www.MarShield.com
ISO 9001:2015, CAN/CSA Z299.2-85 CERTIFIED QUALITY MANAGEMENT SYSTEM
HealthCare Business News I september 2019 71
 Building Barriers
Rolling shields from MarShield
“A good shielding design by a qualified
physicist should occur at the beginning of
the process,” said Petrone. “An inexperi-
enced physicist may incorrectly calculate the
shielding needs and cost you down the line.”
What about radiotherapy?
When it comes to radiotherapy, choosing the
right material isn’t as clean cut. NELCO and
Veritas don’t have a material of choice be-
cause they take into account each project’s
unique needs.
“We’ll use a myriad materials to meet
the customer’s needs and budget require-
ments,” said Miller. “We don’t try to jam a
product into every project and just say this is
what we have and you live with it.”
If the customer has space constraints, then
they may use lead since it has the highest
shielding value of any material. In other cases,
they may use a combination of lead and con-
crete or lead and the high-density concrete.
“As with most things, there is no one-
size-fits-all solution,” said Martin. “The best
shielding material depends on a number of
factors including raw material cost, project
72 HealthCare Business News I september 2019
logistics, difficulty handing and especially the
nature of radiation being shielded.”
For radiotherapy, Veritas usually uses
its VeriShield system, which involves dry,
stacked shielding modules that interlock to
form a leak-free therapy room. It’s structural
in terms of load bearing, consistent in com-
position, shape and density, uses space ef-
ficiently, attenuates a wide range of ionizing
radiation and is modular in nature to provide
design flexibility.
Shield for existing or
future throughput?
“Some may argue to shield for the existing
workload and if the workload increases, add
more shielding,” said Petrone. “Even if this
would be possible, it is a dangerous selec-
tion, analogous to being penny wise and
pound foolish.”
He added that the likelihood that a facil-
ity will forget to redo their shielding design,
leaves them open to a noncompliance situa-
tion, which could be dangerous for the sur-
rounding areas.
To prevent all of that, he recommends
projecting how the caseload may increase
over the lifetime of the unit before installing
any radiation equipment. By doing that, the
initial design will never have to be revisited.
“Most professionals would advise to proj-
ect the absolute maximum steady state aver-
age workload that would ever be reached
during the life of the machine,” said Petrone.
Martin agrees that new and/or growing fa-
cilities should always be looking 10 years down
the road to anticipate future growth. That can
range from considering additional future pa-
tients in a single space to including extra space
adjacent to the current bunker in a design to
easily add treatment rooms in the future.
“Adding extra layers of material to a
room during initial construction is much
more cost-effective than having to add
shielding later,” he said. “Existing facilities
with multiple treatment spaces in operation
are usually adding equipment for more stra-
tegic reasons and should consider the extra
shielding costs in conjunction with their abil-
ity to split additional workload over multiple
treatment spaces.”
Share this story: dotmed.com/news/48328
www.dotmed.com/news
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SOLD OUT Front: 4 Available Featured Listings. . . $500

6 GE DASH 3000 MONITOR SYNTHES 150.119 LARGE BONE OLYMPUS ENF-P4 FIBERSCOPE BES ES2000 CDML-BT
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Avante Patient Monitoring, formerly ORTHOPEDIC TRAUMA SET RHINOLARYNGOSCOPE PHOTOSTABILITY CHAMBER

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ADVERTISER INDEX
ADVERTISER PAGE ADVERTISER PAGE ADVERTISER PAGE

ACE Summit & Expo Hitachi Nationwide Imaging Services

www.acesummitandexpo.com 25 https://www.hitachimed.com/ www.nationwideimaging.com 2
particletherapy/singleroomsolution/ 47
AHRMM Oxford Instrument Healthcare
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www.iba-worldwide.com 45
Altima Diagnostic Imaging Solutions Radiology Oncology Systems
www.altimadis.com 11 iCRco www.oncologysystems.com 41
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www.avantehs.com/ultrasound 27 Image Technology Consulting Imaging Technology
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Beekley Medical
www.beekley.com/ifix 63 Injector Support and Service Richardson Healthcare
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BR+A Consulting Engineers
www.brplusa.com 51 LG Business Solutions Sun Nuclear Corporation
www.lg.com/us/business/commercial- www.sunnuclear.com 39
Complete Medical Services display/it-products/medical-monitors 9
www.completemedicalservices.com 15 Varex Imaging
MarShield www.vareximaging.com Inside Front Cover
CryoSRV www.marshield.com 71
www.cryosrv.com 59 Varian
MEDICA 2019 www.varian.com/intelligent 49
Elsmed www.medica.de 17
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hlthcp.com 29
79
 The Future of Healthcare
Future of radiotherapy:
Efficiency and accessibility
By Dr. Deepak “Dee” Khuntia
While the future of radiotherapy will
continuously evolve through the dili-
gence of passionate physicians and re-
searchers, one thing remains constant:
advancements in radiation oncology
will be designed and developed to al-
low clinicians to put patients’ needs first,
always. Two such approaches — adaptive
radiotherapy and FLASH therapy — will,
when commercialized, prioritize treatment
efficiency and accessibility to do just that.
Where are we today?
We define FLASH therapy as a noninvasive
treatment that relies on external beam ra-
diation delivered in ultra-high doses, at ultra-
high speeds (less than one second), typically
in one to three sessions. It will empower clini-
cians to treat and target cells in seconds, ver-
sus minutes. Initial preclinical research on the
value of ultra-high dose rate FLASH therapy
conducted by Varian and two of its clinical
partners (Maryland Proton Treatment Center
and Cincinnati Children’s/UC Health Proton
Therapy Center), has been promising. To fur-
ther study such ultra-high dose rate cancer
treatments with protons, the Varian FlashFor-
ward Consortium was announced last year.
If we look at adaptive therapy, it is a treat-
ment approach that evolves over time in re-
sponse to the temporal and spatial variability of
the patient’s anatomy. On an increasingly regu-
80 HealthCare Business News I september 2019
lar basis, clinicians can look at physiological
changes (e.g., bladder fluctuations, changes
in weight, changes in tumor size) in the pa-
tient to account for macro fluctuations in the
tumor’s shape and position due to changes in
nearby organs. The approach allows clinicians
to reassess, adjust, and adapt the treatment
plan. Today, this can be completed for certain
patients, but the treatment adjustment process
is a lengthy and laborious one. Aggressive and
innovative work is currently being done to turn
this 2 – 3-day long process into a treatment de-
signed to enable adaptive treatments in a stan-
dard radiotherapy timeslot. If we can achieve
this, the process will be easier on the patient
and clinics will be able to treat more patients in
the abbreviated period of time. The future of
adaptive radiotherapy leverages artificial intel-
ligence in order to segment and map out the
anatomy, target where the tumor is, and opti-
mize quality assurance of the treatment plan.
Accessibility + intelligent
advancement = adoption
Once these modalities leap relevant regu-
latory hurdles, treatment and real-world
scalability still will be imperative to clinical
adoption of these approaches, and the mod-
ern-day reality is that the time, resources,
and training needed to implement new ap-
proaches also are obstacles. Currently, just
“airdropping” linear accelerators (LINACs)
to countries around the world won’t achieve
meaningful outcomes. The technology is
appreciated, but without the appropriately
trained personnel to manage the machines
— which can be sparse in developing coun-
tries and communities — the ability to treat
patients will still be limited. The industry is
being challenged to develop treatment tools
that decrease the time it takes to learn and
understand the technology. This will stream-
line training and ultimately boost access to
care. Knowledge-based learnings tools, or
artificial intelligence, has the power to move
the needle as well.
Artificial intelligence tools have been in the
market for several years and, looking ahead,
the next step is to bring this type of technol-
ogy into radiation oncology even more. Le-
veraging AI to better understand where the
tumor is, which tissue needs to be avoided,
etc., is an example of the near-term applica-
tions of intelligent radiation technology.
The future of radiotherapy will offer a
personalized, flexible, and dynamic long-
term treatment strategy that can offer better
experiences to clinics large and small — and
to patients around the globe.
About the author: Deepak “Dee” Khuntia,
M.D., is the senior vice president and chief
medical officer at Varian Medical Systems.
Share this story: dotmed.com/news/48329
www.dotmed.com/news
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