Many radiology departments, imaging centers and clinics have adopted PACS for the promise of cost-savings enabled by eliminating film. While that goal requires modification when specialists and referring physicians continue to request film, the use of high-quality laser imagers has enabled radiology practices to meet that demand.

Bill Fitzgerald, chief operating officer for Multi Imager Service, an authorized service contractor for Agfa, Kodak and other OEMs notes the changing trends that maximize the effectiveness of print activities. They are seeing much more reliable systems in the marketplace, coupled with many OEM service contracts that have decreased in price for routine maintenance activities.

"There are maintenance schedules with a film odometer that measures the  number of films that has run through the unit," he notes. Typically preventive maintenance activities are required every 10,000 prints. "The machines are becoming much more reliable than they were 10 years ago" - a scenario reminiscent of the lonely Maytag repair man.

"Historically, you had a printer in the nuke med department, one in ultrasound, one in CT and one in MR," he says. "Now we're seeing one centralized printer with increased speed, sorters and multiple film sizes per laser." Since the overall number of prints has decreased with the advent of PACS, remaining hard copies must be produced efficiently and with an eye on cost.

Depending on the physical dimensions and requirements of the radiology practice, administrators must select the appropriate printer configuration to meet their needs.

Dispersed on a network

John C. Litchney, administrator for the department of regional radiology at the Cleveland Clinic Foundation, discusses the rationale for deploying a dozen plus Codonics Horizon imagers throughout their extensive department.

The small footprint (less than two square feet) of these tabletop printers, and the efficiency they afford the technologists who can print films in proximity to the imaging modalities where they are performing exams is appreciated. While film in ultrasound is not used, their laser imager configuration includes having one printer paired with one CT and one MR scanner, and no more than three modalities on any one printer. All of their archiving of images is accomplished electronically via PACS.

"Codonics offers color printing on paper," explains Litchney. "That, combined with the advent of 16-row CT scanners that can produce color 3D images in post processing, that's where we find ourselves using this product." Most of their referring physicians have  appreciated the versatility of these imagers, capable of printing on film or paper.

One of the other benefits of printing on Codonics DirectVista paper is a  reduction in cost compared to printing on film. For example, with traditional film, a 14-by-17-inch sheet could be as much as a 60 percent lower using paper. Many referring physicians prefer to place the paper print into their patient charts. Color printing proves useful in ultrasound, nuclear medicine, MR fiber tracking, multislice 3D and orthopedic applications as well as fused images produced by modalities such as PET/CT.

Litchney describes their use of a mobile PET/CT unit, where they place most imaging studies on CD disks. "The Codonics Horizon is on that mobile unit, and while we don't use it for most things, we do use it for color printing. It can do 80 to 90 sheets per hour."

They began using the imagers in 1999 and have needed to replace only one unit to date. Codonics offers a service program where they "swap" a new printer unit for one that has malfunctioned. A new machine is shipped to the department, personnel remove a "smart card" with set up information for the original machine, place it into the new one, and the imager is ready for use immediately. They return the original machine to the company.

The Sony FilmStation 14X17 Dry Film imager is another compact desktop imager that is capable of printing a film in less than a minute, according to Andrew Osiason, MD, co-director of New Century Imaging in Oradell, N.J. He considers this a plug-and-play system that is easy to install, and describes it as DICOM compliant. The imager can be installed in either a horizontal or vertical position and has casters for mobility with a LCD front panel and simple system for loading film.

By combining the newly developed print head with Sony's blue thermal film, the FilmStation is designed to produce an increased level of image quality as well as edge-to-edge printing. It features a high-resolution 320 dpi thermal head technology with 4,096 shades of gray and a maximum density rating of greater than 3.2. One additional feature, full-time head protection, positions the FilmStation imager's print head into a park mode when it is idle.  This feature is especially beneficial in mobile applications.

Centralized printing

Each department or facility needs to run as efficiently as possible, and for some that means configuring printing activities into a central imager where all modalities are networked into a single station. The important issues for these imagers is that they must have multiple size film capability coupled with sorter functions that separate various imaging studies into different slots for ease of identifying the specific study a technologist seeks. Image quality is another critical factor in meeting the needs of busy radiologists, specialists and referring physicians.

Fujifilm Medical Systems USA offers a variety of imagers including the Fuji DryPix 5000 used in the St. John's Mercy Medical Center in St. Louis, Mo. This 900-plus bed hospital with Trauma Level 1 designation performs exams in both inpatient and outpatient  imaging settings. They have 30 operating rooms, three intensive care units, and a newborn intensive care unit.

Iwona Llorico, RT(R), ARRT, supervisor of imaging services, says their DryPix 5000 laser imager which was installed in May 2004, supports nine Fuji IIP CR units, with a back-up for the operating rooms. While they are basically filmless, this imager provides backup if their PACS goes down. They can print three sizes of film, 14-by-17, 10-by-14 and 8-by-10, and she describes that their radiologists are pleased with the excellent quality of images that are produced. They are using blue base film (versus clear base) because it looks more like conventional x-rays of the past.

"One very important factor is that this printer outputs in true size, so that 100 percent of the image is on the film," Llorico explains. Since other printers may produce film prints that are 96 to 98 percent of the image, that causes problems  especially in orthopedic surgery. Some x-rays sent to the OR may be used for measurements to determine an implant size and position, so it becomes critical for them to have adequate information.

Additionally, these printers have the ability to print to the edge of the film. When images are printed within a border, they must either reduce the size of the image, or crop the edge of the image and print full size, which could result in deleting important diagnostic and possibly demographic information. Also, the DryPix 5000 has received 510(k) clearance from the FDA for use with full-field digital mammography (FFDM) devices.

David C. Held, radiology service engineer at University Community Hospital in Tampa, Fla., describes their use of two Kodak DryView 8900 laser imagers and four Kodak DryView 8700s that have been upgraded to be compatible with their PACS. This 431-bed hospital conducts about 120,000 imaging studies per year. Once they deployed PACS in December 2004, they cut their film printing from 20,000 films per month to 2,000.

The first of their two 8900s is located in the main control area, where all of their CRs, two CTs, six ultrasound units and two interventional rooms send images to be printed. The second unit is located in the film file room, where they produce films for referring physicians. They placed their four 8700s in key areas such as the operating room, emergency department and MRI area which is located at the other side of the hospital from their radiology department, and the radiation therapy area.

They set up a dedicated stand-alone network for radiology, which means that when a film is requested, it is printed almost immediately. Within their network, any modality can print to any printer, both in this hospital, and their sister hospital, which is approximately nine miles away. The redundancy they've achieved with this system is necessary in this portion of the country where power outages occur frequently.

"We chose the Kodak 8900s for a couple of reasons," says Held. The speed, the sorting bins, the ability to load different film sizes are all important. "But we knew that the service we had received from Kodak on our existing machines was great, so we went with Kodak."

Another benefit to these systems is that all of their printers run off the same type of power outlet, so if they need to replace one printer with another, it becomes a plug-and-play operation. All they need to do is to change the commands as to which printer should receive images to facilitate seamless operation.

Nicholas Piscitelli, BS, RT, director of radiology at Radiology Associates of Venice and Englewood in Florida runs two offices that are full service radiology departments, not free-standing imaging centers. They accomplish 800 exams per day in their peak season including imaging studies from digital mammography, bone density studies and barium enema studies to PET/CT, MRI, 16- and 64-slice multidetector CT, nuclear medicine and ultrasound modalities with two Kodak DryView 8900s at each office.

"We had [Kodak DryView] 8700s for years, and we were very happy with those, but when we switched to digital mammography they were not approved by the FDA for printing those studies," says Piscitelli. "Once the 8900s were released, they were quickly approved to print the high resolution required by the FDA for these studies. And they've proven to be highly reliable machines."

The facility built their own PACS to enable efficient use of their radiologists' time. With 30 terabytes of storage and high-powered reading stations with RAID 10 backup, they have five T1 lines connecting their two offices. They can transfer images from any modality to any of the four 8900s when one is down for service which occurs about every 10,000 images produced and takes about four hours to complete. They print films for both referring physicians and patients.

"Our patients are very mobile and want their images when they go back home in the spring," explains Piscitelli. While they can produce CD copies of the images or provide web access for physicians, most of their referral base prefers film.

Conclusion

There are many important factors involved in making the best use of laser imagers. After carefully assessing the specific needs of a department or facility, a decision must be made as to whether a centralized or de-centralized configuration is best. Reliable equipment is a critical component to accomplishing printing activities. The central imagers are fast and offer some benefits, while the smaller units provide versatility and take up less space when that is an important consideration. As acceptance of digital images becomes even more widespread and more physicians are able to access images electronically, the need for film should continue to decline. In the interim - and likely long into the future - laser imagers provide an important service to many physicians and patients.