CR + PACS = Efficiency

Healthcare facilities that have coupled computed radiography (CR) and picture archiving and communications systems (PACS) have begun to realize the workflow enhancements and improved effectiveness anticipated by deploying these technologic advances. CR vendors have worked to improve throughput while maintaining excellent image quality to facilitate patient care - to the benefit of healthcare facilities and patients.

Efficiency gained

Sally Grady, RT(R), director of imaging services at Florida Hospital-Celebration Health describes their state-of-the-art hospital designed for the digital age of radiography that completed construction and opened in Disney's town of Celebration in 1998. Although they originally designed the department to implement direct digital capabilities in x-ray, they did not believe those systems were quite ready for prime time. So just prior to opening, they installed two CR systems, an Agfa Healthcare CR 25 and CR 75 and an ADC 70 digitizer to meet their needs. The CR 25 is designed as a decentralized single-plate system, while the CR 75 is the high-volume multi-plate system.

Grady says she has not processed film from the day they opened.

The Florida Hospital System, of which Celebration Health is one institution, operates seven campuses under one bed license in the Central Florida area. This system admits more than one million patients per year to their inpatient facilities, and completes between 700,000 and 900,000 imaging studies per year.

"We were looking to solve several issues, such as productivity," says Grady, who also worked to implement Agfa CR installations in the other six hospitals across the Florida Hospital System. "Before I took Florida Hospital Kissimmee live, we looked at FTEs and we found we were 23 percent more productive at Celebration." She believes that is due to the use of CR in their department.

Another benefit to having deployed CR across the entire network is that they can now provide 24 hour-a-day radiology coverage for all hospitals with the 54 radiologists, including a number of subspecialists, serving to read the studies from all institutions.

Grady believes that their combined CR/PACS solution has decreased length of stay for many of their patients because it shortens the interval between imaging studies if physicians decide they need additional examinations because they did not gain all of the clinical information from the first study. Many of the physicians can review images from home, and order additional imaging studies they consider essential.

The technologists are able to spend more time in the x-ray room, which decreases patient anxiety. Once the cassette is loaded into the ADC-Compact (the plate reader right outside the door), they return to the room to review the images on the quality station console.  The ADC-Compact Plus employs stacking methodology, where the technologists can stack up to 10 plates and leave, and the machine will automatically process them in order.

Grady's department uses a PACS team with six people who were chosen to provide both CR and PACS support. Although it is a joint effort between radiology and IT, they have chosen to manage both systems from the radiology side because the expertise in CR technology takes precedence. She notes that other hospitals may place the PACS team within the IT department, but they have followed this path because radiologists were very comfortable with it.

Enhancing workflow

At Illinois Valley Community Hospital in Peru, Margy Frey, BS, RT(R), administrator and director of diagnostic imaging department reports that they have configured their CR network with Kodak DirectView CR 850 and CR 950 systems to manage the images for the patients in their 100-bed hospital. While they do not perform any invasive procedures or angiography, they do complete conventional x-ray and some interventional scans. They went live with CR approximately a year ago.

Illinois Valley installed the CR 850 to provide robust redundancy to the operation in case they would have a network problem or in the event that the 950 required maintenance. Frey describes the system as extremely easy to use with touchscreen functionality.

The CR systems utilize a rigid plate that is tested to 45,000 cycles to insure durability. The system is built on the concept of non-contact scanning where the imaging plate that is inside of the cassette is used without ever touching it.

Both systems feature an internal battery to keep the machine operating to protect data from being lost from either internal or external causes of unplanned shutdown, including network outage and power failure. Also, an internal computer processes and stores 2,000 images.

Besides the two CR readers, they have three remote operating panels (ROPs) to ID cassettes and perform quality control activities while reducing unnecessary backlog at the primary readers and to facilitate workflow. In addition, they installed the Capture Link clustering tool at the beginning of 2005, which further streamlined workflow. With Capture Link, they can access any CR on the network enabling any ROP to "talk" to any CR that resides on the system.

"As far as processing time goes, it certainly cuts it down from conventional x-ray," says Frey. "The advantage is when you couple the CR with PACS."  

Illinois Valley had CR approximately six months before they went live with another vendors' PACS due to construction delays. Frey notes that Kodak was extremely helpful in integrating the CR systems with the new PACS. "We've had excellent service with Kodak…they're very supportive."

The Christ Hospital in Cincinnati, Ohio, uses Fujifilm SmartCR single-plate readers located strategically throughout the hospital to facilitate technologists' work as they accomplish the 50,000-plus CR radiographic procedures annually, according to Jane Kettlehake, director of imaging. This 555-bed, not-for-profit acute care facility has been recognized as one of the best hospitals in the United States by U.S. News & World Report and for the past nine years, has been awarded Cincinnati's Most Preferred hospital.

The SmartCR system with a three-square-foot footprint is designed for low and medium volume or distributed imaging environments such as imaging centers and clinics or placement inside the x-ray exam room. It consists of a compact reading unit for imaging plate scanning and erasure, as well as a console workstation for patient ID, image preview, reprocessing and transmission to PACS.

In addition to the SmartCR units, Christ Hospital installed the Velocity-U (upright) and Velocity-T (table) direct capture equipment, which Kettlehake describes as a radiographic room that allows you to do CR imaging but in a cassetteless manner, because the CR plates are built into the system. This equipment was placed in their busy emergency department where they see about 12,000 patients per year, with virtually all of them requiring images that are captured on these systems.

"We have both systems, the upright and the table, and it's a wonderful technology," says Kettlehake, who says the ER physicians really appreciate the efficiencies afforded by these systems as well as excellent image quality. She describes the time from the moment the patient is positioned until the radiologist and emergency physician have images to review is almost instantaneous.

The Velocity systems employ storage phosphor detectors built into the machines for image capture. This technology is the same as that used in cassette-based imaging, but there are no cassettes used with this equipment.

The Charlotte Medical Clinic, a multispecialty practice with 31 internal medicine specialists that is part of the Carolina Healthcare System in North Carolina is making good use of IQue CR from Konica Minolta Medical Imaging, says Technologist Joanne Harrison, RT(R). They focus on traditional exams including flat-plate abdominal, chest x-rays, and extremity work. With about 600 chest exams per month, although fewer during in summer months, they complete approximately 850 to 900 imaging studies per month.  

They do not perform complex radiology studies, but focus on traditional exams including flat-plate abdominal, chest x-rays, and extremity work. With 600 chest exams per month, although fewer during in summer months, they complete approximately 850 to 900 imaging studies per month.

As a technologist with 40 years of experience, Harrison describes the IQue as very easy to learn and use with approximately a 20-second time frame from placing the cassette until the study is ready for viewing. The touchscreen functionality has made the system user-friendly, even for new personnel.

"It's a simple system to learn, and it tells you what to do," Harrison says with a smile. "There's not much typing to do except for patient information, and you don't even have to use the mouse much."

Designed as a stand-alone system, the IQue incorporates intelligent software to facilitate technologists' learning curve. It is designed to automatically recognize each image within an exam and apply the appropriate processing algorithm for that image. For example, most chest exams include both PA and lateral views with each requiring a specific algorithm to produce best image quality. With the IQue, the technologist would instruct the system as to the body part being examined, and the system determines automatically whether a PA or lateral film was captured, and applies the correct algorithm.

The system also incorporates a self-learning capability that adjusts images to the specific user's preferences. This feature is intended to enable any technologist, experienced or not, to consistently generate the best possible diagnostic images with minimal training.

The system uses the same reader and rigid plates employed in the Xpress CR line. The plate technology features 100 percent iodine to provide x-ray absorption and noise reduction in conjunction with Konica Minolta's patented multi-frequency processing software.

Modular, scalable…maximizing flexibility

Buffalo Medical Group in Williamsville, N.Y., performs between 80 and 100 studies per day between their two sites where they do general imaging studies plus fluoroscopy for the 100 physicians who serve as the referral base. Their x-ray workhorses are four Xpress CR units from Konica Minolta, says Anne Haffa, RT, assistant manager of imaging services.

The Xpress CR is modular and scalable to be used in a variety of healthcare settings, and can be deployed throughout the institution.  For example, an emergency department could have one unit; the primary radiology department could install three. All of the CRs can be networked so that each system comes with a reader and control station. A plate can be registered on one control station, and put (post image capture) on any reader, and the images be sent to a designated control station. This means that the department can maximize resources, so that if one reader is busy, and another is not, the image can be sent to the one that is idle.

Haffa notes that their Xpress CR units have more than met expectation, following extensive comparison activities. She especially appreciates the fact that they can insert more than one cassette at a time.


As the healthcare establishment has embraced the digital age with a variety of imaging modalities that produce digital data, such as MRI and CT, the basic imaging studies found in traditional x-ray lagged behind. Today, many more institutions are turning to CR to bridge the gap, and facilitate the transfer of electronic images to wherever the physician needs to view them. The efficiency enabled by deployment of these systems - often further fueled with PACS - has enhanced patient care and promoted more effective utilization of clinician time.