A Revolution in Waiting: Digital Radiography Plows the Path for Going Digital in Mammography

Faced with shrinking budgets, staff shortages, aging equipment, the higher cost of switching to newer technologies such as DR and CR, growing workloads, limited space, increasingly high patient and referring clinician expectations, the radiology administrator has a daunting task. Digital radiography and digital mammography have been touted as systems than can revolutionize how medical imaging is done - but have the benefits of these technologies proven to be true?

This article looks at the experiences at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H. Dartmouth-Hitchcock, which has a tradition of providing its patients and referring clinicians with the latest advances in cost-effective imaging technology, has thought long and hard, and decided to invest in the digital revolution.


As part of its long-term strategy to invest in the future, Dartmouth-Hitchcock Medical Center made the conversion to digital imaging in the general radiographic department with the purchase of six digital radiography and four computed radiography units in 2003. This purchase was made as part of the center's long-range migration to a picture archiving and communications system (PACS) and a comprehensive electronic medical record system.

For radiology, the path to the future is clear; screen film-based imaging is going the way of wet processing. The much talked about but slow to take off digital revolution is starting to impact radiology in the same way it has the consumer camera market - particularly in the general radiography department. Why limit yourself to film when digital imaging offers increased speed, high quality, improved staff productivity, low consumable costs and convenience?

The first digital radiography systems were introduced in the U.S. in 1998. Two years later, the first digital mammography systems were cleared for sale. Digital mammography followed digital radiography because there were major technical challenges in going digital in women's imaging and the benefits of a digital image capture system in mammography are different than they are in digital radiography.

For most of the last dozen years, there was only one choice for going filmless - computed radiography. Now there are more than a dozen different options for going digital in the general radiography department and a growing number of alternatives for going digital in women's imaging.

Early indications at DHMC are that DR and CR have lived up to their reputation of providing 30 to 40 percent gains in technologist productivity, increased imaging room capacity, while providing long-term cost savings.


Justifying digital radiography purchases with increased productivity and lower overall cost arguments is possible for the general radiography department, particularly if you include costs that are more difficult to measure - such as improved patient care and increased productivity of the radiologist and referring clinician. However, making a productivity argument for moving to digital mammography is more difficult.

The high cost of entering the digital imaging arena - three to four times the cost of an analog system - makes many hospital administrators put off the decision to go digital. Hospital administrators, conditioned to examining their department finances quarter by quarter and expecting a quick return on investment (ROI) for their major acquisitions, quickly realize that DR/CR and PACS will not provide ROI payback solely by eliminating film costs and staff reductions in the film library. The economic decision to go digital requires a longer time horizon.

Granted, savings will be achieved with the elimination of film and low paid film library staff, but that generally is not enough to pay for the move to digital imaging. This is where many hospital executives halt the move to digital imaging and PACS - the payback isn't there.

The real payback is in productivity increases for the highly paid staff - the technologists, radiologists and referring clinicians. These productivity increases, coupled with enhanced productivity of the imaging equipment and space, although difficult to quantify, are huge. While reaping the gains of these productivity increases, the real benefit becomes clear: improved patient care.

Some referring clinicians at DHMC were astonished at how the PACS increased their productivity, job satisfaction and ability to treat their patients. Most of the referring clinicians at DHMC now have the ability to review imaging studies with their patients immediately following the study. The use of wireless laptops in the examining room has opened up a whole new way of working with and treating patients. How do you put a dollar number on these enhancements for your ROI calculations?

Many radiologists also expressed their satisfaction at improved productivity, reduced stress and improved job satisfaction. During this era of radiologist shortages, improved productivity and job satisfaction play an important role in retaining your radiologists. Retaining radiologists is a far better strategy than recruiting radiologists in a difficult job market.

The same holds true for technologists. Currently, the shortage of technologists - which is approaching 25 percent - is greater than that of nurses. Many hospitals have had to resort to the employment of more costly technologist-travelers to fill their staffing needs. The going rate for a MR, CT or mammography traveler can add up to $180,000 a year. Improving the productivity and enhancing the job satisfaction of the existing technologists makes more sense.


In 2003, Dartmouth-Hitchcock installed its first digital mammography system. The digital unit joined four conventional film-based mammography units handling up to 100 cases a day, over 30,000 cases a year. The conversion of the mammography department from film-based to digital has been slower to take off than digital radiography and is even harder to justify with an economic/productivity argument.

The slow take off was due, in part, to the stringent requirements to comply with the FDA's Mammography Quality Standards Act as well as technological issues as the manufacturers learn to display, move, retrieve and store the larger case files of digital mammography.

Initially, the change-over to digital mammography is difficult for everyone - it's different for the technologist who is suddenly asked to view images on a monitor rather than a view box. She is given the ability to adjust contrast and brightness, highlight soft tissue on the edge of the breast or magnify an area of interest - all of the things that in the days of film-based imaging would have required repeated x-rays or call backs to the hospital for additional views. The radiologist also is faced with a new viewing experience, sometimes complicated with electronic artifacts he or she never had to contend with in film-based imaging. But in the end, many realize that they see more. The ability to adjust the image to fit their particular needs or to view areas never possible in film-based imaging is a powerful new enhancement to mammography.

One of the driving forces in the conversion to digital at DHMC was the large expansion to the medical center now nearing completion. This expansion includes a satellite radiology department and a renovation of the existing department. The satellite department will bring radiography, mammography and ultrasound adjacent to the clinician's offices - saving patients the inconvenience of time-consuming long walks to the main radiology department. Faced with stationing radiologists at the satellite facility, digital imaging offered the option of keeping the radiologist in the main department and sending digital images back to the main department.

In the early planning for the satellite mammography facility, the department was faced with two options to handle the expected mammography volume; install three conventional analog mammography units with their associated film multiloaders and wet processing units with their high demands for maintenance and consumable supplies or buy two more expensive digital mammography units, which offered the same volume with one third less staff and the elimination of the consumable supplies, plumbing and maintenance required for wet processing. This coupled with the ability to keep the radiologist in the main department made the decision to use digital mammography a clear, cost-effective choice.

The healthcare needs of tomorrow will require that diagnostic imaging service providers rapidly produce the high-quality images, transmit them broadly, display them in alternative ways, and then archive and retrieve them efficiently.

Within the women's imaging and general radiography departments, digital systems are starting to replace film-based imaging systems. The advantages of digital are many - higher technologist productive, better utilization of space, fewer repeats and, as in the case at DHMC, fewer staff. Because the new systems capture and convert x-ray images into a digital format within seconds of the exposure, the technologist can quickly preview the image for quality assurance. Unlike analog images, a digital image can be transmitted electronically for reviewing on a workstation or printed on film if necessary, and stored electronically. Digital images can be optimized on the workstation to better view the desired anatomy and to compensate for under or over exposure. And all-digital computer networks allow patients to use the most convenient location in our healthcare network for their exam with the assurance that the procedure will be accurately and quickly completed and transmitted to the radiologist for reading in the shortest possible time.

To justify bringing their department into the digital realm, healthcare executives need to take a longer-term view, rather than a short-term view with a quick return on investment. With digital mammography, the productivity workflow advantages are harder to document than with digital radiography. But we are working at it.

The bottom-line benefits of going digital are clearer in digital radiography than they are in digital mammography - improved patient care, increased staff and equipment productivity, and the potential to attract a greater number of referral patients and physicians. The increasingly savvy patients who want the best healthcare will soon be demanding digital mammography - we have to be ready.

Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Dartmouth-Hitchcock Medical Center (DHMC) is an integrated academic medical center located on a 225-acre campus in Lebanon, N.H.

DHMC comprises Mary Hitchcock Memorial Hospital (a 396-bed tertiary care hospital), the Dartmouth-Hitchcock Clinic (a network of more than 900 primary and specialty care physicians located throughout New Hampshire and Vermont), Dartmouth Medical School and the VA Medical and Regional Office Center in White River Junction, Vt., the Children's Hospital at Dartmouth and Norris Cotton Cancer Center.

The first clinical x-ray in the United States took place at Dartmouth College more than 100 years ago. Today, DHMC performs more than 200,000 radiologic exams annually, employing the full range of imaging modalities, including New Hampshire's only PET/CT scanner.

The October edition of Health Imaging & IT named DHMC one of the Top 10 hospitals in the country for innovation and advancement in its imaging programs and information technology.