OEMs are paid high fees to service this largely benign, but sometimes nasty, modality.
Stress on the engineer—that’s what’s different about servicing a magnetic resonance imaging (MRI) machine, says Duane Dantes, a service engineer and owner of Dantes Medical Imaging Inc in Jacksonville, Fla.
“MRI is truly a massive integrated system,” Dantes says. “When the machine will not do something, you have to be able to visualize the signal flow in your mind. Every biomed tech I know must work on 500 pieces of equipment. They are overwhelmed by the MRI. There is something about a monster piece of equipment that carries a psychological impact. I’m the same way around a linear accelerator.”
It isn’t just the size of the MRI machine. There are physical characteristics that can be dangerous, say Dantes and others who work on the modality. The magnetic field in the bore of the machine is so strong that patients and medical staff both have to be careful with ferrous metals. Whole pallet jacks that weigh more than 100 lbs have been sucked into the mouth of an MRI machine. Patients with pacemakers or metal implants could face injury or death if exposed to the magnetism. Janitors have had mop buckets disappear into MRIs and dust pans sucked out of their hands. MRI service technicians have to use special nonferrous tools.
“You can’t walk in with a crescent wrench,” says Francis Vonder Haar, vice president and general manager of Diagnostic Imaging Services for Masterplan Inc, a Chatsworth, Calif-based company that provides engineering and biomed services in 32 states. “We have special copper, titanium, and nonmagnetic stainless-steel tools. You never shut the magnet down, so you’ve got to be very careful what you do around it.”
Magnets are not the only concern. The cryogenic system that uses liquid helium at 450° below zero to chill the magnetic coils so that superconductivity is achieved is so cold that technicians can suffer serious freeze burns if there is a mishap. “It would instantly freeze you so it’s a bad burn,” Vonder Haar says.
In addition, if the magnet “quenches”—a rare situation during which an electrical short or some other factor causes the temperature of the helium to rise in the cryogenic chamber—the liquid helium will turn to a gas. Escape valves on top of the machine allow the gas to escape, and in rare instances, escaping helium in a closed MRI room has replaced the oxygen, causing technicians to asphyxiate, Vonder Haar says.
“I was standing in the aisle in a manufacturing plant and one of them quenched,” Vonder Haar says. “There was a cloud and a shooshing sound. It was a huge room so there was no danger. It’s such a rare event. If it happens once in a lifetime of a magnet it’s a lot, and a magnet will last for 50 years.”
Because MRI machines are fed radio frequency (RF) signals in combination with the magnetism to get the shifts in hydrogen proton activities in the patient’s body that are computed into images, the machines must be shielded from outside sources of RF. Outside RF can distort images, so test images (phantoms) have to be run and RF leaks corrected.
Magnets also tend to get slightly out of position over time and must be physically and electronically shimmed to “maintain the homogeneity of the magnetic field,” according to Vonder Haar. “Shimming is very specialized and very important. It’s often left to specialists. “I don’t do ramping and shims,” Dantes says. “I will either refer that or send it back to the OEM” [original equipment manufacturer].
While its physical properties make the MRI machine stressful to work on, Dantes says an equal stress on the engineer arises from the downtime for physicians and patients while the machine is being maintained or repaired.
“The revenue stream coming through that piece of equipment can be as much as $10,000 an hour, although most are closer to $4,000. For them to be down creates a number of stress factors. I’ve actually had a radiology director follow me around wanting to know how soon I’d have the equipment ready,” Dantes says. “Most biomed guys can’t work under that type of pressure. They usually call me for phone support, and then they don’t have the confidence of their administrators.”
Even more than CT scanners, MRI machines tend to be modalities that hospitals let an outside company handle. That company is often the OEM, even though independent service organizations (ISOs) like Dantes’ company say they can do the service and maintenance for “under half” of what OEMs typically charge.
The OEM Advantage
MRI systems may be even more imposing electronically than they are physically. The only moving part in the machine is the table on which the patient is rolled into the magnetic field chamber. The minute atomic signals in the body that become images have to be collected, analyzed, and transformed by computers into something a radiologist can interpret. Magnets may last forever, but MRI software upgrades are frequent, as advancements in such elements as imaging time occur. ISOs admit that these upgrades are one area where the OEMs have a clear servicing advantage—so much so that some MRI consultants recommend using only OEMs for service and maintenance.
C. Wayne Hibbs, a consultant who operates Dallas-based Hibbs & Associates, says MRI failures “are almost always software related” and calls outdated software “the Achilles’ heel of MRI.”
“Every 6 months, some manufacturer is coming out with new algorithms for newer, quicker scans. If you’re not keeping up you’re in trouble. If I have a 5-year-old scanner, the magnet is fine, but not the software protocols. I’m still using a two-channel signal access when the new ones are eight-channel and the scan time is one half to one fourth.”
Signal acquisition time and signal reconstruction time have been drastically reduced by software upgrades, says Hibbs, meaning that scan times with the patient on the table also have become much shorter.
“What I find is that no matter how good the in-house biomeds are, the hospital typically leaves the MRI on a service contract with the OEM,” Hibbs says. “Of the 40 or 50 hospitals that I deal with, the vast majority have elected to stay with the OEM.”
Hibbs says hospitals and clinics may save money for a few years by using in-house or ISO service for MRIs, but eventually, the need for upgrades will require going back to the OEM.
“When you go back to the OEM and say you want an upgrade, they won’t sell you the new warranty until they’ve checked out what’s been done to the machine. They won’t guarantee until they bring your system up to date, so they’ll hit you with an incredible service contract,” Hibbs says. “They make more off service than they do selling the equipment in the first place. Selling the equipment is a loss leader after paying the sales component. The money is in the service contracts.” Hibbs says he advises most clients to stay with OEMs for MRI service. “I’m saying that the best option for most organizations is to take the OEM over the long term on MRI. It’s a different story for CT, ultrasound, and the other imaging equipment.”
Staying with the higher priced OEM may be good advice, but the low margins at which most hospitals and clinics operate often leave them searching for alternatives. Some large health care providers have mounted in-house servicing divisions and are now marketing services to other health care providers outside the system. David Francoeur, CBET, is executive director for service operations for TriMedx LLC, an Indianapolis-based clinical engineering firm. TriMedx, says Francoeur, began as an in-house entity for St. Vincent Health, one of the larger health systems that make up Ascension Health, the country’s largest Catholic nonprofit health care system. Now, TriMedx has more than 200 customer contracts and manages clinical engineering departments for more than half of the Ascension Health hospitals.
TriMedx provides clinical engineering management but employs only a few service technicians, Francoeur says. Typically, it works with existing hospital staff or finds a technician for the hospital to hire. TriMedx functions as a source for parts and oversees the preventive maintenance (PM), repair, and upgrade of the equipment, but the technician directly involved is a hospital employee. Because the technician is employed by the hospital, there is no travel time and the hourly rates are less than an OEM charges, Francoeur says.
According to Francoeur, TriMedx oversees the service on 35 to 40 MRI machines manufactured by various OEMs. Like ISOs and OEMs, TriMedx is happy to hire OEM-trained technicians, but it also trains technicians or sends them to school.
“MRI is probably the highest level of training that I can offer to individuals,” Francoeur says. “I need to trust them, because they are expensive to train. It’s not unheard of for the salary of a good MRI technicians to be in the six-figure range.”
Part of TriMedx’s mission, Francoeur says, is to save its client hospitals money, not just in-service expenses, but also in deciding when and how to replace equipment. “For every dollar I save, the hospital is saved from having to earn $20,” he says. “A hospital buys an MRI at a life cycle of about 7 years, but the reality is that the life cycle is 12 to 14 years. As it gets older, it breaks a lot more, so it is imperative that we get involved so we can give our customers the best bang for their buck.”
It’s not unusual, Francoeur says, for TriMedx to procure an OEM software upgrade on behalf of a client. “As a collaborative service provider, we are eager to work with the OEM and educate the client about what they can get through an upgrade.”
ISOs often buy machines so they can order OEM parts for other clients and learn how to service the machines, Francoeur says.
“There are people out there who will buy an MRI just to tear it down and write service programs,” Francoeur says. “TriMedx also has to prove that we can do a job equal to that of the OEM for less money. I have to demonstrate to the customer that I can get training (for their technicians), and I have to show them I can get parts. I have to show the customer that going with us will be OK.”
An irony of the MRI service business is that sometimes the OEMs themselves will hire ISO technicians to work on the OEM’s behalf. If the OEM has a service contract that covers not just its MRI system that a hospital owns but a competitor’s machine that the hospital owns as well, it may bring in an ISO technician familiar with the competitor’s model to service that machine. Or it may use ISO technicians to cover areas where its own staffing is thin.
“I have been successful with several OEMs by asking them to give us training and access to parts in exchange for us becoming their service provider, so that their product looks good for our client,” Francoeur says.
Dantes says his company does a lot of stand-in work for OEMs who have global service contracts that cover competitor’s equipment. “They won’t train me on their own equipment, but they’ll train me on a competitor’s,” he says. “As far as that customer is concerned, I work for that manufacturer.”
Most service engineers say they do monthly PM checks on MRI machines, making sure the various systems are clean and working. They run image phantoms to check image quality and to guard against RF leaks. Because MRI is a complex but normally stable machine, the cost of completing these routine tasks is easy for ISOs to compute when they make bids to get service contracts. But bids to do service on machines that previously have been under a different company’s contract should be approached with caution.
“One of the things we want to do before we take a contract is to look at the recent service history on the machine and watch the system before we set a start date,” says Jim Foros, an MRI service technician with Deccaid Services Inc, an ISO headquartered in Deer Park, NY, that services machines on Long Island and in New York City. “Magnet problems tend to be pretty expensive. You have to make sure you’re not inheriting an expensive problem. If you have a magnet problem, that can wipe out that service contract for a year.” Once Deccaid is satisfied the machine it is bidding on is safe to take on, the company can save a customer significant money, Foros says. “In most cases, we can do it for about 60% of the OEM’s first offer,” he says. However, he says OEMs that know they are being bid against may lower their own bids.
Foros says money for servicing has tightened up in recent years. “We have to find ways to become more efficient at what we do,” he says. “It’s quite a challenge lately.”
George Wiley is a contributing writer for 24×7.