In 2012, Intermountain Healthcare, a hospital system based in and around Salt Lake City, Utah, established an in-house service program for the majority of its imaging devices. While still retaining some original equipment manufacturer (OEM) service agreements, Intermountain now has a team of 16 engineers that service 3,000 pieces of equipment spread out over 450 miles. The health system has a similarly diverse system for training its engineers, using a combination of resources, including internal training, independent training centers, such as the Solon, Ohio-based Radiological Service Training Institute (RSTI), which provides basic, in-depth X-ray training, and classes offered by vendors, including GE and Toshiba.

“We’ve found that effective, depending on what our needs are,” says Jeff Koford, imaging equipment service program manager for Intermountain Healthcare. When engineers are first hired at Intermountain, they go through on-the-job training, where they shadow a more senior engineer. Engineers have later been sent to RSTI in Ohio to receive X-ray and C-arm training; GE’s training facility in Waukesha, Wis., to learn about maintenance for X-ray, CT and MR equipment, including GE’s Precision 500D radiography/fluoroscopy system; Toshiba’s Institute of Advanced Imaging in Irvine, Calif., for training on their Aquilion CT system; and the AllParts Medical multivendor training center in Nashville, Tenn., for training on the GE Proteus radiography room and on GE’s portable X-ray machines. RSTI’s president, Dale Cover, says his company offers a good value for training inhouse engineers to service their own equipment, which is much less expensive than OEM service contracts.

RSTI has been operating for 30 years, providing everything from basic X-ray, CT, MRI, ultrasound and nuclear medicine courses to training that covers specific models of X-ray, mobile C-arms, and cardiac catheterization lab and CT equipment. “A service contract is a safety net,” Cover says. “A lot of places feel safe, but it’s the most expensive delivery for service.”

That’s not to say Cover believes service contracts don’t have a place in hospitals. RTI offers a course in capital asset management, helping hospitals strike the right balance byhaving some service contracts and some equipment maintained in-house. For example, if an expensive cath lab isn’t under a service contract and no one on staff is trained on it, there’s a risk of excessive down time.

“It all depends on a hospital’s willingness to take on risk,” Cover says. “If they’re doing the service themselves, they carry the risk of having to provide the service and they carry all the cost. Some repairs may be costly but you’re going to save overall, because you can save a lot of money on other systems.”

Koford of Intermountain says the health system put together a committee of imaging managers and clinical engineering managers and directors, took 18 months to look at all the options, including third-party and insurance options, and aimed to figure out the arrangement that would increase uptime, decrease contract costs and create better response times.

They decided to bring most equipment in-house, aside from CT and MR, which are serviced through a partnership type relationship with the OEMs. “I think we’ll always need to maintain the relationships with our OEMs to a certain level,” Koford says.

“The relationships assure us we’re working closely with our OEMs to service the equipment.” Intermountain has three levels of imaging engineers. The Level 1 engineers work on laser imagers and injectors, Level 2 engineers work on X-ray machines, C-arms and some CT and MR machines and Level 3 engineers work on all equipment.

“We prefer engineers that have had imaging experience,” Koford says. To determine the system’s training budget for the fiscal year, Koford says they look at what equipment their team can take on in the next year, and at the cost-to-benefit ratio, justifying the training budget by each piece of equipment.



Parts and training
Cover says RSTI’s dedication to training separates it from competitors, many of which provide training in addition to their main business of selling parts. Jeremy Probst, chief operating officer of Technical Prospects, is at a company that offers training on Siemens equipment as well as parts.

Probst’s father, Robert Probst, worked as a CT service engineer for Siemens for 18 years, then started buying and selling systems and doing turnkey installations, before moving into warehousing parts. In March 2014, the company completed construction of a $2 million training facility. Training was a natural extension of Technical Prospects’ parts business, Jeremy Probst says.

The company already had Siemens imaging equipment set up for testing and repair, and adding training follows the shift of hospitals using independent service organizations and in-house service programs to lower costs. Technical Prospects trains engineers from ISOs and hospitals, and they can take advantage of the discount on parts. “If they’re servicing the equipment and have to buy parts from Siemens, they’re paying 30 to 80 percent more,” Jeremy Probst says.

Koford says it’s helpful to “test the waters” of a parts provider by taking training courses from them first, then buying a limited number of the parts. “It’s really tough to just jump in with both feet and not know what you’re getting into,” Koford says.

Having a parts business is particularly helpful for Digit Systems International, an ISO that works in the European market, where the industry for independent service providers is growing rapidly. Diego de Saint-Albin, managing partner of Digit Systems International, says it’s difficult to access tools and parts in Europe. “It’s not a mature market like it is in the U.S.,” de Saint-Albin says.

“Not only can we train and keep our engineers up to speed with technology, we have all of our tools in-house.” International Medical Equipment & Service (IMES), a parts and training business with a big focus on the Toshiba CT market that was recently acquired by Richardson Electronics Healthcare, offers free expert technical support to the in-house and thirdparty service organizations it trains.

“We’ve been able to take hospitals’ inhouse service groups and show how we can back them up with the support to make their personnel better and stronger,” says Trey McIntyre, founder and general manager of IMES. “When you add that up, you have a stronger, cost-efficient in-house program.”



Good, better, best
Digit Systems International holds two training programs a year through its sister company Tunemedix in Portugal, and stresses the importance of on-the-job experience for its engineers. “While classes provide the basic understanding of the equipment, the troubleshooting exposure actually happens in the field,” de Saint-Albin says. “We promote training plans where engineers are faced with increasingly difficult issues in hospital environments.

The power of that is 10 times greater than sitting in a classroom.” GE Healthcare provides training for the company’s field engineers and customers with in-house service programs, and both groups attend the same classes, says Lewis Richards, director of the Testing Center of Excellence and productivity programs for GE Healthcare Global Services.

Hospitals are also supported by a team of remote technical engineers that assist with the troubleshooting and support for many of the multi-vendorsystems in GE’s installed base. GE also offers tools, such as a problem and solution database with more than 8,000 support entries, remote connectivity to systems to aid in troubleshooting, and electronic performance support tools and materials to help with the quick identification of issues.

“Our training at the Testing Center of Excellence provides the materials, tools, and knowledge that expand modality expertise across whatever multi vendor systems they need to support,” Richards says. “This leverages and maximizes existing talent within a facility.”

Technical Prospects employs engineers to train other engineers, something Jeremy Probst says separates good training from mediocre. There’s also a difference in price, with Technical Prospects’ courses ranging in price from $7,000 to $10,000 for a two-week program.

“Siemens, being the OEM, offers its courses specifically to its engineering staff and contracted hospitals that have negotiated in training as part of purchase of new equipment,” Jeremy Probst says. “People pay a significant premium.” OEMs believe they are in the best position to train people, since they have designed the equipment.

Siemens offers customized programs for its customers who are transitioning to inhouse staff, giving them the same training as Siemens engineers and, in the interim, providing a level of OEM support until their in-house staff is fully prepared to take on all equipment. Transitioning is a three- to five-year process, says Scott Varnum, vice president of Siemens Service Strategic Accounts, who started his career managing in-house service teams for the Veterans Health Administration, New York-Presbyterian Hospital, and an integrated delivery network in western Massachusetts.

In addition to teaching engineers how to fix equipment, trainers can help customers better understand workload on the devices. “For Siemens, we’re looking at the overall relationship between us and the customer,” Varnum says.

“It’s not all about our service portfolio with customers.” Philips provides training to in-house service staff at training centers in Cleveland, the Netherlands, and Singapore, as well as at their customers’ facilities and online, says Richard Gerler, director of technical operations for multi-vendor services for Philips. Online resources include Philips’ NetForum Community, an online forum where users of CT, MRI, and PET/CT can share experiences, and InCenter, where individuals with a subscription can download product service information, manuals, and guides.

For non-Philips equipment, Philips Multi- Vendor Services offers support and technical training through AllParts Medical, a parts sourcing and distribution company that Philips acquired in 2011. The facility has more than 40 training bays for classes on all imaging modalities from virtually every major OEM, Gerler says.

Philips also offers a program for in-house health care technology management teams that have decided they are ready to move beyond the direct support of OEM or third-party service, Gerler says. The program adjusts contracted direct service coverage to in-house support level arrangements at no additional charge during the term of the agreement. “Through this transition period, customers work alongside Philips’ engineering team to gain further insight into how to troubleshoot, repair and maintain the equipment,” Gerler says.

“This program was specifically designed to support customers’ changing business needs.” In Taiwan, UnisonMed Academy offers hands-on training for multi-vendor CT, MR, nuclear medicine and cardiology systems to in-house hospital service and third-party engineers from all over the world, while also providing remote support via phone or email, and even sending trainers overseas, says Arthur Tsou, UnisonMed Academy’s general manager.

“We send doctors or radiologists overseas to teach local medical and health care personnel to operate the system and enhance their image diagnosis technique,” Tsou says. “In the near future, we intend to get involved much deeper into the academic circle and hospital management, which includes nursing and senior management. We aim to be a linking bridge among industry, academia and the hospital.”

A computerized world
Training providers have been challenged with imaging equipment that has become increasingly computerized. Cover, of RSTI, says the institute’s basic X-ray courses have been including more computer interfacing and software-based training as systems have become increasingly more complex.

“Everything is really moving more toward the computer world,” Cover says. “From the computerized standpoint, we’re teaching them to be computer engineers as well as electronics engineers.” Jeremy Probst of Technical Prospects agrees that there is more IT in the imaging space and their training includes teaching engineers such things as how to load software and diagnose problems using service software. Engineers now more than ever need an IT skill set to be effective, he says.

“The engineering teams that are working on this equipment need to have a higher understanding of IT and computers as a whole,” Jeremy Probst says. Tsou of UnisonMed Academy says most systems still need biomedical engineers to operate and maintain the image quality, which can’t be substituted by IT engineers. “They do have separate skill sets,” Tsou says.

“Therefore, we provide the fundamental electronics, fundamental radiation and physics for the IT engineers at the first stage. And we also have the theory and hands-on practice [to] help them get into [the] biomedical engineers’ world without too many problems.”

Education before training
There’s also been somewhat of a gap in education. There is no specific degree or certification required to service imaging equipment, and while more colleges are launching biomedical engineering programs, few offer specific training for imaging devices, Jeremy Probst says.“A lot of colleges are bringing people up to speed on electronics and biomedical engineering.

As a company, we’ve brought in an intro to X-ray and intro to CT training course to bridge that gap,” Jeremy Probst says. “We feel that’s going to be a growing space in the next several years.” Caldwell Community College & Technical Institute in Hudson, N.C., offers future biomeds a foundation with a biomedical equipment technician program that ends with an associate’s degree in applied science.

John Noblitt, biomedical equipment technician program director at Caldwell, says students take courses in physics, math, safety and standards, along with medical instrumentation. There’s also an imaging course, which provides exposure to X-ray machines, and a 320-hour hospital internship where students work as a biomedical equipment technician with supervision by a more experienced technician.

Most graduates go to work in the hospital setting. However, some graduates have accepted positions working for manufacturers as field service technicians, with a few accepting positions in the imaging technologies service industry. “If you come out with any two-year degree, you’re basically going to be starting out on a lot of the portable equipment, such as defibrillators and electromechanical devices, doing safety testing,” Noblitt says.

“After employers see promise, then they may send you to X-ray school. An OEM like GE or Philips usually requires a couple of years of experience before offering employment. However, a few students over the years have accepted positions such as these by OEMs.”