Working Smarter with CR

Agfa's CR 30-X tabletop digitizerThe days of computed radiography proving itself are clearly in the past as more and more hospitals and imaging centers embrace the benefits of CR and even migrate to the next generation. For both new and veteran users alike, CR is about working smarter to better serve the needs of the patients, physicians, and facilities.

Hospitals and imaging centers recently making the switch to or adding CR report they have seen remarkable improvement in the delivery of patient care and work productivity even during the first few months. For facilities with many more years of experience, they continue to see improvements with the introduction of new options, systems upgrades, and software that help them fine tune quality of care and workflow.

Service where you need it

One veteran facility with many years of CR experience is the University of Virginia Health System in Charlottesville, Va. It includes the UVA Medical Center, a 572-bed Level 1 trauma center. Rich Hooper, R.T. (R), (CV), medical center manager, diagnostic radiology, has "seen the system evolve" during the 15 years he's worked with CR from what he calls a "boat anchor" to the system it is today — "small, fast, and flexible." Because of these changes and the reduction of system costs, CR has moved from a centralized service to a decentralized service.

Since the installation of their first CR unit nearly 17 years ago UVA Health System has been loyal to Fuji, its sole CR vendor. Today, they "have already expanded to most every part of the hospital. With 27 CR readers, 30 IIPs [Image and Information Processor, an integrated patient ID and image QA review station], and another multi-plate reader expected in the next month or two, we have just about maxed out our capacity of CR," says Hooper. The units can be found throughout the facility, including one in each x-ray room, most critical care units, outpatient sites, and operating rooms, as well as in a recovery room, pediatrics, orthopedics, and urology. The units — including five Fuji Carbons and five Fuji Smart CRs — are responsible for more than 150,000 CR imaging procedures a year, accounting for 42 percent of all radiology exams.

Similarly, Cook Children's Health Care System based in Fort Worth, Texas, has decentralized its radiology services with the installation of 12 Konica Minolta CR systems on the main campus and at satellite locations within a 35-mile radius. The pediatric healthcare system installed its first CR in the Cook Children's Radiology Imaging Center in Hurst, about 15 miles from the main campus, when the center opened in 2000.

After three years of CR experience under their belt, they switched vendors with the installation of Konica Minolta CR units. "I guess you could say we cut our CR teeth in those initial three years," says Linda Boatner, RT (R), CRA, administrative director of imaging services for 32 years. "At the time we began to phase in CR at our other locations, we had the opportunity to investigate newer technology. Konica allowed us to set custom algorithms for patients as small as two pounds to adult size. We also like the fact that the Xpress was not a slot-loading configuration, which allows for faster throughput. Konica was innovative and willing to listen to our needs and we established our partnership."

As part of their radiology decentralization, units are located in the 282-bed medical center's main radiology department, the critical care units, and an urgent care center. Units also are located at the Specialty Clinics Building adjacent to the main campus and two other outpatient locations. Cook Children's is a filmless environment. Nearly 73 percent of the 110,000 imaging procedures performed system-wide annually are CR. They report a 99.9 percent uptime for the Konica equipment. The addition of CR units outside of the traditional radiology unit allow for faster diagnosis, smoother workflow, and expedient patient care.   

One-spot management

Having a decentralized radiology service doesn't mean running from unit to unit to manage the system. Tracking the performance of the CR units and techs is now as easy as sitting at a desk at one location. Jeff Harrington, MS, a medical physicist at Columbia St. Mary's Health System in Milwaukee, Wis., uses Kodak's Administrative Analysis and Reporting software that came with the installation of the Kodak Directview CR system last fall. It was just a few months ago that the multiple-location health system, comprised of four hospitals and 30 clinics, made the switch to CR. Currently they have seven Kodak CR systems, including two DirectView 975 CRs and two DirectView 850 CRs at each of the three main sites, plus another DirectView 975 at the River Woods Outpatient Center. According to Harrington, about 25 percent of the 300,000 imaging procedures performed throughout the healthcare organization are CR.

"I can access the CR statistics from all of our sites right from my desktop. I use the statistics to calculate repeat rates, and to look at the average exposure indexes for specific exams," says Harrington. "The statistics can be sorted by technologist, body part, projection, date, exposure index, repeat reason, or time of exam."

Harrington continues, "Having all of these statistics is a physicist's dream, al-though a technologist or administrator can certainly perform this analysis. It's really interesting, and it's really kind of fun."

At UVA Health System, Hooper manages one division of radiology over seven locations from his desk. He performs a "constant review of overall image quality with respect to processing parameter and consistent use of grids, techniques, and other imaging equipment. Utilizing VNC [virtual network computing], I am able to support many of the staff and clinical areas at remote locations. This allows me to make changes to processing parameters and the GUI [graphical user interface]."

He adds that over the past few years the biggest change he has seen in CR is the "much improved GUI" and more recently the "Flex UI allows us to do post processing and QA of images much more effectively." Hooper monitors the system on a daily basis making sure the parameters are all set the same for consistent results.

No lost films

Ease also comes in the way of sending images and reports to physicians. Last year Samantha Sizemore, director of imaging services for Holston Medical Group in Kingsport, Tenn., was a member of the radiology task team that selected Agfa Healthcare as their CR vendor. The medical group, consisting of two main diagnostic centers and nine satellite medical offices with x-ray services, in the fall of 2006 introduced the use of CR to their facilities with an Agfa CR 25 and Agfa CR 30-X. They are looking to install two more CR 30s shortly.

Sizemore says of the 72,000 images they processed during the end of last year, 10,240 were CR. One noticeable improvement? The ability to "cut out the messenger." With film, Holston relied on an employee to courier film from the imaging facilities to the 123 providers in the network across eastern Tennessee and southwestern Virginia. "Film could get lost or delivered to the wrong office," she says. Reports are now sent electronically to physicians who can review them from any location. She adds that their turnaround time has been reduced to less than 24 hours versus up to 72 hours for film.

Fast and tech-friendly

Techs also report how easy it is to use CR. Greene Medical Imaging found that their techs who only worked with film and never touched a computer found the transition painless. Mark Naclerio, manager for three years at the Catskill, N.Y., imaging center, says of making the transition to the Konica Minolta IQue CR system in 2005 that "even our non-computer techs can handle it. We expected a big learning curve, but we found in reality it became very simple." The 12-year-old center employs two radiologists and seven techs, and processes approximately 7,000 CR images annually.

The IQue has separate input and output bays which allow the input bay to stack one cassette when another cassette is being processed. The Control Station is automated and the Automatic Exam View Recognition function recognizes the body part and automatically applies the correct image processing parameters making setup simple for the tech. Speed is also part of the package — the IQue processes 90 plates per hour.

Cook Children's Boatner states, "The Konica touchscreen is easy to use and technologist-friendly. In addition, the techs like the ability to customize various configurations to meet workflow needs for each area." She goes on, "The technologists had been using chemistry and film for years and they initially felt that the change to CR slowed them down. After the learning curve, their attitudes reversed 180 degrees. Our technologists and physicians cannot imagine a day without the use of CR." Cathy Ross, RT (R), diagnostic imaging manager, adds, "The techs whiz through it; it is so fast."

The latest software for the Regius Xpress CR system enables technologists to easily append studies, image zoom for quality assurance at the console, and filter lists to adjust study parameters.

With 40 radiologists and 200 technologists (50 are diagnostic techs) at UVA Health System, Hooper says it is a great benefit for techs to have only Fuji units throughout the UVA facilities. He notes for techs transferring between departments, there is no time spent learning a different system since each of the units "looks the same, acts the same, and works the same."

Sizemore notes that an advantage for techs using the Agfa CR 30-X at Holston is that "there are fewer steps involved, [for instance,] load cassette and stamp it at the same time, and there is quicker viewing," adding that techs "are able to see the image while the scan was in progress." Seeing the image on the screen as it is scanned provides an opportunity to make adjustments without having to wait until the exam is complete. No longer must they develop film to see the results and redo the entire procedure if there is a problem.

Productivity plus

When film is used, the only way to evaluate the quality of a procedure is to undertake the time-consuming task of checking each film. To evaluate the quality of a CR procedure, one need only check the reports available on the system. If there are problems with CR images, a retake may be called for. The system captures that information. Techs are able to insert a code for the reason for the retake. At Greene, Naclerio says "most retakes are due to [patient] motion." He also notes that in the 1Å6§5Å0Ü5  years they have used the CR system "retakes have reduced by 50 percent."

The reports generated on Columbia St. Mary's Kodak CR system are not all critical or in need of improvement. Harrington says, "I was really pleased to see how dose-conscious our radiologists and technologists are." He routinely communicates his findings with managers and techs. "One technologist at each site is responsible for actually making the technique adjustments based on my report," he says. In evaluating the reports, Harrington is able to note if "specific exams have higher repeats." In some cases, the information also is relayed to Columbia St. Mary's School of Radiologic Technology.

Productivity at Holston Medical Group can be measured in numbers. With the installation of CR, they went from performing 220 exams per month to 510 exams per month with the same number of FTEs (full time equivalents).

Space saver

The compact size and computer technology employed in CR systems not only lends itself to decentralization, it also saves space in the radiology department. At Holston, Sizemore says with the Agfa CR 30-X (a single cassette-fed tabletop digitizer) "there is no longer a need for space for a darkroom and/or file room. This space is now utilized for other productive revenue means — the lab has taken the space." At Greene Medical Imaging, they were able to go from three radiology rooms to two and enlarge the waiting room.

Even units that are not tabletop, like the Kodak CR 975 don't take up much room. Columbia St. Mary's has been able to take advantage of the compact size (52 inches by 41 inches by 30 inches) by placing systems at the point-of-care throughout the organization's facilities.

Workflow wonders

With CR workflow, improvements begin at the point a technologist enters patient information into the system. From then on, patient information is captured electronically and available to access with touch of the screen or keyboard. The number of steps during an exam is reduced because the information is captured and there is no film to physically process, retrieve, review, and deliver.

The introduction of Fuji's FCR Pocket ID PDA eliminates steps in a technologist's workflow by permitting him or her to download patient information from the workstation and then move throughout the facility to perform exams.

For a lead technologist or radiologist, reading reports no longer means handling stacks of film. Like a radiology manager or medical physicist, he or she can sit at a desk to review the exam. From there, the reports are sent electronically to practitioners — eliminating the need for more handling and a courier service.

The storage of CR images is one of the final workflow improvements. CR systems integrate with PACS allowing for electronic storage of files. Hooper says he likes the efficiency and ease of storing CR images in their PACS at UVA Health System.

With decentralization and the ability to capture the patient information and exam at point-of-care, the workflow is more manageable than if the patient has to be moved around the hospital. The exam is done where it is needed, saving time and energy, and improving workflow.

The centralization of the electronic management for decentralized CR imaging provides an efficient way to communicate information. Running to different rooms, floors, and buildings is replaced by gathering and transmitting information from a single workstation.

Patients first

Ultimately all the benefits of CR are passed on to patients who receive care and treatment more quickly. Nowhere is efficiency and saving time more sensitive than in treating children. Cook Childrens' Ross says they have seen the benefits in using CR in many areas, especially "for screening during suspected child abuse cases. In those situations anxiety can run high and CR has allowed us to cut the imaging time in half."

Techs never having to leave a patient's side make a patient feel more secure and creates a safer situation. Hooper said that as a result of installing Fuji CR units, UVA Health System has seen a reduction in problems that may have resulted because a patient was left alone during an exam.

Because of the portability and decentralization of CR units, patients do not necessarily have to move throughout a facility for radiology exams. A CR system in an emergency room area not only means a quicker diagnosis during a critical time, it also means less stress on the patient without having to leave the area. At Cook Children's they have two units in the ER, with one considered as a back-up. At UVA Health System, the additional CR units in ICU have cut processing time in half during life-threatening situations.

Improvements add up

The measurable benefits of computed radiography add up to improved work-flow, productivity, and patient care. From the moment the tech begins the exam process, the benefits begin for all involved in the exam. Patient care is improved with point-of-care CR exams, speed, and accuracy. Techs are able to work faster, more efficiently, and have greater control of the quality of the image. Hospitals and imaging centers notice cost savings, improved productivity, and improved service to patients. They all work smarter with CR.