Case Studies: Optimizing Digital Radiography

Central Baptist Hospital: Reducing Costs, Keeping Staff, and Pleasing Patients with DR

By Bill Broaddus, RT (ARRT), Director of Radiology Services, Central Baptist Hospital, Lexington, Ky.

Central Baptist Hospital is a 371-bed medical research and educational center located in Lexington, Ky. The hospital offers some of the most advanced medical facilities, technologies and capabilities available in the region including a respected heart program, a Cancer Care Center, and family-centered obstetrics, among others.

The radiology department, which supports many of the programs, performs approximately 100,000 procedures each year. However, the radiology umbrella that we have does not include mammography because we have made that a separate center, and it also does not include nuclear cardiology because the heart studies are performed at a center for heart exams. Of the exams, some 70,000 are diagnostic in nature. The hospital's radiology department is comprised of five radiologists with four general radiography rooms and three radiography and fluoroscopy rooms. Today we are totally digital and each of our modalities is connected through a radiology information system (RIS) and our images are available for viewing anytime, anywhere through a web-based PACS.

Pondering that move
After planning to make the move to a PACS since 2001, we went with Agfa IMPAX in November 2003 and at the same time installed Agfa ADC Compact and Solo CR (computed radiography) systems. The move from film to CR did make us more efficient in many respects, yet we were still lacking in productivity and efficiency because we were still using cassettes that require a technologist to go back and forth to a central processing area. Keeping an eye out for new technologies to improve our facility, it quickly became apparent to us that our next migration would be to a digital radiography (DR) system due to the efficiency of the systems from many perspectives as well as the patient-care benefits.

We put off replacing our diagnostic and fluoro equipment until we had the funding and administrative support so that any new room we installed would be DR-capable. We installed two Siemens AXIOM Aristos FX systems at one of our imaging centers in January 2004 and plan to install another of these systems at a new imaging center in October of this year. More recently, we installed the AXIOM MULTIX M in February of this year to replace an older CR system in our main hospital. For each system, the benefits that we projected have proven true in every instance.

Essential site visits
Taking highly inquisitive and straight-shooting personnel to do site visit evaluations of these types of system is absolutely essential and in our case, this included an in-house radiology engineer, a modality supervisor, and a general staff member. Our experience with the Aristos FX unit was very positive. Yet, the room we had to work with for our next install was not large enough to accommodate the advanced robotics of the FX. So, we considered the MULTIX M. We liked the single- plate design, which allows a technologist to take the cassette out of the table and put it in the motorized upright detector stand which saves the cost of buying a second plate. We also were wary of systems that have the plate built in to the table because when you go to do cross-table work you still have to use your CR cassettes, and we were looking to avoid multiple systems.

With the MULTIX M, you can do work in the table, on top of the table or take the plate out which can be placed in a holder on the side of the table. A grid attachment allows technologist's to do cross-table work. Also, the plate has enough cable on it that when patients come in on stretchers it can be placed under them just like you would a cassette, and the radiographs can be done just like they would be done with a CR cassette. The system produces images in four seconds for quick review which is much easier on patients, especially the elderly or those in a great deal of pain because follow-up images can be done right then without coming back and re-lifting the patient to get them repositioned for that exposure.

'You're done?'
The productivity in every room that we have put DR has increased and it has been well accepted all around. A common patient response after the exam is complete is 'you're done?' That's how fast the systems are.

As for daily hospital productivity, a four-day snap shot of work with the DR systems reveals that we perform an average of 28 patients a day. Of those, 32 percent are extremities, 18 percent spine, 17 percent are chest, and 14 percent are hips and pelvis. We couldn't do this many patients with CR or analog.

In the context of an imaging center, prior to DR they were doing 400 patients a month. After a year of using the Aristos FX, they were imaging 1,000 patients a month with the same number of technologists and no one has even asked for more staff. It is unlikely that the center could have gone from 400 to 1,000 using the analog equipment.

In the hospital, we don't expect the same kind of spectacular throughput increase because we generally see patients with higher levels of acuity who take more time to scan.

Because of digital radiography we do not expect to have to reduce our staff, and at the same time we won't have to hire new staff as rapidly either.

Happier patients
One of our goals when moving to DR was to keep the technologist at the patient's side for safety and reassurance, which we view as important. Using DR, the technologist is with the patient throughout the course of the exam. So, just having a faster experience isn't the only benefit.

Patients are consumers who have many choices these days, so it benefits the hospital to provide a safer and more pleasant experience for them, and we can get better productivity for our business through the technologists and technology.

Like the Maytag guarantee
A good sign of a quality system is forgetting it's there. Service on the FX system is a little like the Maytag repair personnel, you never see them. All the DR units we're gotten from Siemens have needed little or no repair.

Siemens also offers a 'train the trainer' program that involves training a few members of your staff who then train the rest, which worked well.

Hospital for Special Surgery Lessons learned from CR plow the path for DR

By Helene Pavlov, MD, FACR, Radiologist-in-Chief, Hospital for Special Surgery, Professor of Radiology, Professor of Radiology in Orthopaedic Surgery, Weill Medical College of Cornell University, Ithaca, N.Y.

Although the Hospital for Special Surgery is a 172-bed facility, we service a large outpatient population. We perform approximately 160,000 imaging procedures annually with 12 full-time, board-certified radiologists, five clinical fellows and two research fellows. We are an orthopedic rheumatologic hospital, so all imaging examinations are of the musculoskeletal system. The imaging department, having outgrown the main hospital site, has 12 different areas in three buildings.

In addition to computed radiography (CR) units and direct radiography (DR) systems, our facility has five MRI units, one CT system, three ultrasound scanners, a dual-head gamma camera, and nine C-arms. We currently are using mini-PACS for soft-copy image reading as well as film/hard copy reading.  We distribute film to all of our referring clinicians. We are, however, rapidly moving into a filmless environment.

Not all images are created equal
About three or four years ago, we launched into digital radiography with a Philips CR system. DR was not yet well established or affordable. However, over the last several years more vendors began to develop DR systems and the technology progressed to a point that we started to seriously consider its applications. Also, it became clear to us considering the hospital's continuing expansion, that imaging needed to become more efficient operationally. Based on our research of the systems, DR was the way to go.

In our daily activities, we require incredibly rapid turnaround, and DR is a much more efficient way for the technologists to process images. They can see right from the get-go whether they've positioned the anatomy accurately, and if the image quality is appropriate. The ability to obtain the image without moving cassettes, combined with almost instant image review permits rapid patient throughput.

The relatively easy transition to Philips Medical System's Digital-Diagnostic TH about one year ago would not have been possible without our relatively painful, although educational CR transition. In general, CR quality for extremity work was just not where we needed it to be. The ease of technologist post-processing was detrimental to quality. There was a major learning curve for us to get CR to the level we required. Some of our routine views were not readily compatible with the system reader modes. Our goal was to tweak the CR system to do what we needed and retrain the technologists. Philips was excellent in providing appropriate applications people for us to work with regarding our technical issues.

For general practice CR and DR systems are very good, but for orthopedic work you need to acquire images of very small body parts and demonstrate exquisite detail of very small abnormalities such as a small fracture in a finger. We need very, very fine detail. With CR, we evaluated every post-processing technique that was offered for every portion of the skeleton to assure that we were getting optimal image quality. Now we're going through the same process with DR to get the system to do exactly what we need and thus assure DR quality.

Our routine examination of both knees is a good example. This examination was performed on one film with the patient in a standing position. Because digital equipment focuses on the center of the image, the detector would focus on the area between the knees. The quality was terrible, and the technologists painstakingly tried but could not post process to adequate quality. We had to re-educate the technologists and adjust the system and our protocols accordingly. In the end, we created an anatomy database with detailed instructions as to how to image every portion of the body for the various views we require. It was very labor intensive but was worth it and we did boost image quality in CR - and we are now applying what we learned through our DR installations.

A double life with CR and DR
We cannot phase out CR completely because some of our views require cassettes and cannot be accomplished on the current DR systems. We have a combination of both CR and DR equipment, eight DR rooms and 10 complementary CR units up and running with another eight DR ongoing installations. An example of our need for CR is the axillary view of the shoulder which requires a vertical-oriented cassette positioned next to a supine patient's shoulder. Companies are developing or have developed ways to have mobile DR receptors, but currently that's not an option for us.

All's well that ends well
The technologists are very satisfied with DR because it is less physically demanding; they are not required to lug around cassettes and it makes their jobs faster and the image quality is generally better. The other thing that the technologist will tell you, particularly about the Philips equipment we are using, is that it is very user friendly. They appreciate that they can see the image instantly and all the patient information and technical factors are right there. They do not have to run back and forth to enter information. It's just very efficient. These days we are all pushed for speed and accuracy and the DR system fits right into that objective.

DR has helped to improve our patient throughput and the referring physicians appreciate the film quality.
The happy endings are there, but what we cannot stress enough is that putting in CR equipment and DR rooms is much more than just buying the equipment, plugging it in, and life is wonderful. There is a lot of work involved in getting the image quality results that you expect.

We try to get out and share what we have learned and have presented our knowledge at Northwest Imaging Forums in which professionals share their experiences with digital imaging systems.

We pride ourselves on providing superb musculoskeletal images. We make sure that the techniques we use and the positioning of patients and the resulting images are of ultimate diagnostic quality. We evaluate every aspect of image quality and efficiency constantly, and tweak the machines to make sure that they do what we need them to do, and then some.

MeritCare Health System Applauds Productivity, Image Quality; Lower Radiation Dose with DR

By Brent Colby, Physicist, and Cathy Holmen (RT)(R), Regional Manager for Radiology, MeritCare Health System, Fargo N.D.

MeritCare Health System of Fargo, N.D., includes two hospitals with a combined total of 583 beds and more than two dozen outpatient clinics that together generate more than 300,000 imaging procedures a year. In addition to our primary facilities in the Fargo/Moorhead area, our imaging centers serve patients throughout North Dakota and Minnesota.

After converting our hospitals and five imaging clinics to a digital workflow with PACS and CR, we realized the next step was to add digital radiography to our fleet of digital imaging technology.

While CR provides excellent image quality and enables an affordable and efficient digital workflow, DR technology has the capacity to enhance productivity and image quality, while lowering radiation doses. Therefore, DR is a target for higher volume areas in hospitals and clinics, pediatric areas and facilities where we plan to install new x-ray systems.

Our evaluation team involved representatives for the major users of digital imaging including technologists, radiologists and managers. Through site visits, managers and technologists evaluated ease of use and productivity, while radiologists evaluated diagnostic image quality. The physicist measured technical quality factors including resolution and contrast/detail as well as radiation dose.

We installed our first DR system in 2004 at our Southpointe outpatient clinic, which conducts 19,200 general diagnostic exams a year, and an almost equal number of ultrasound and mammography exams. Most of the general diagnostic procedures are referrals from orthopaedic specialists located in the clinic.

Productivity gained
We expected DR technology to be at least twice as productive as CR technology, and we have not been disappointed. Based on our evaluation of CR and DR in adjacent exam rooms at the SouthPointe clinic, we can report that the room with a Kodak Directview DR 9000 system captures more than half of the imaging exams with capacity to spare. In addition to providing the ability to conduct upright, weight-bearing exams requested by orthopaedists, the new DR system enhances productivity in three ways:

  1. Images are available from the DR system in just 8 to 10 seconds, compared to 50 to 60 seconds for our CR rooms  
  2. The system's U-arm allows the technologist to move the detector and x-ray tube simultaneously
  3. The U-arm also minimizes the need to move patients during positioning which simultaneously expedites the exam and enhances patient comfort.

Exam times are critical because the imaging exam and appointment with the orthopaedic specialist are scheduled back to back -with just 15 minutes allocated for the exam. So if the imaging center is running behind schedule, we could cause delays in the orthopaedists' office.

Image Quality
We have seen continuous improvements in image quality from CR systems in recent years, but the design of CR technology potentially limits the gains that can be made in this area. We believe that the amorphous selenium detector used in our DR platform offers a much more efficient method of collecting image information and therefore presents a greater potential for significant improvements in radiation dose and image quality. Image enhancement software also plays an important role by enhancing images from our CR and DR systems

The chart above indicates the increased image quality and reduced radiation exposure offered by the use of DR technology at our facility, as compared with CR and film/screen systems.

The column, "kVp" is the radiographic kVp selected for the exam. The "entrance exposure" is essentially the skin exposure (including backscatter) to the ACR abdomen phantom.  The Cu filtration column indicates whether the image was shot with a copper filter in the beam (this generally lowers the patient dose). The "mesh" is the mesh pattern visible on the image. This is essentially a test of the high-contrast resolution (higher is better). Columns 1, 2, 3, 4 and 5 refer to contrast/detail objects seen in the phantom (more objects seen is better). The "% contrast" value is the percent contrast visible on the image (lower is better). The bottom row of the table shows the results from a new low-dose radiographic film/screen system (KODAK Hyper Speed G Medical Film) that we are rolling out to our film/screen-based facilities.

Dose reduction for pediatrics
While productivity is normally the driving force behind implementing DR technology, we believe that its ability to reduce radiation earns it a place in serving our pediatric patients. This summer we placed an order for a second DR 9000 system for the MeritCare Southwest Clinic, which contains a lab, imaging center and pediatricians' offices. We selected this model because of its flexibility in performing a wide range of exams - and the fact that its design allows a child to sit in lap of a parent during most exams, which reduces stress for all involved.

We also ordered a Kodak DR 7100 system for the MeritCare Jamestown Clinic, 90 miles west of Fargo. This clinic performs 6,000 general diagnostic imaging exams a year, and that number is growing each year. As we evaluated the overall cost of converting from film to digital capture, we discovered that installing a DR room at this site would involve much less remodeling than a CR room. Since space is extremely limited at this facility, even the modest requirements for storage and processing of cassettes was a problem. At this facility, we elected to order a DR system with a tilting table and a pull out bucky/detector for extremity and chest exams.

Justifying DR
Enhanced productivity of personnel and equipment accounts for a large part of the financial payback in a DR purchase. Since one DR room provides the same patient capacity as two or even three CR or film/screen rooms - revenue generated per employee is much higher. Another major advantage is the ability to repurpose exam rooms with desired imaging equipment that drives additional revenue. Eliminating the cost of film, chemicals, darkroom space certainly contributes to the cost payback.
While we feel the payback on our DR systems is attractive, we are not making DR installation decisions based on productivity and efficiency alone. Within our health system, these decisions also are  based on other factors, such as reduced doses for patients, increased image quality and the ability to implement next-generation digital technology as we replace x-ray systems

<<Click here for ACR Abdomen Phanton Scores>>

Princeton Orthopaedic Associates Networking, site visits key in choosing the right DR

By JoAnn Zygmunt, Manager of Clinical Support Services, Robert H. Simpson, Jr., Director, William G. Hyncik, Jr. Director, Princeton Orthopaedic Associates, NJ

Princeton Orthopaedic Associates (PDA) is one of the largest Orthopedics practices in New Jersey and has been in existence for about 35 years. We have three locations with two being in Princeton and the third in Monroe Township, N.J. which is about 10 miles from Princeton. Primarily PDA is an orthopedic group with 11 orthopedic surgeons who cover all of the sub-specialties within orthopedics with the exception of pediatrics. We have three physiatrists, three podiatrists and we have six physician assistants. Overall, currently PDA has 135 staff members.

The practice also includes three physical therapy facilities as well as a single room surgery center. Generally speaking, our organization is entirely self-contained and we also have our own IT department and billing.

Our facility performs about 2,000 imaging procedures a month, or approximately 24,000 every year.

Shifting to the digital world
A few years ago it became clear to us that many of our physicians desired to be able to view the images on computers. Our first move towards that goal was to install a 1.5 tesla MRI unit a year and a half ago. Simultaneously we added what we consider to be a sort of PACS-lite situation with  GE Radworks which in combination with a web server got our doctors viewing images online remotely.

Our facility does between 250 and 300 MRI procedures a month. The MRIs are read by our local radiology unit, all electronically in real time.

The move to DR
We were living on borrowed time with our previous x-ray technology and had to make a change. Two of our x-ray rooms were 20 years old and used Raytheon equipment that is no longer manufactured. Another of our rooms was Continental which is also no longer manufactured and our fourth room was at least 10 years old.

Our team spent two years investigating the best x-ray solution for our facility. In looking for a new x-ray solution, we traveled all over the country doing site visits. Networking can be very important in getting good information about these systems and at the time. We have a lot of colleagues who had already looked at a lot of these systems we reviewed at some facilities that were using CR, some that were using DR and some that were using both. The biggest thing that struck us was that the departments that were using both seemed to eventually phase out the CR. Based on our site reviews, the CR systems were unpopular  because the systems are very cumbersome and the physicians didn't seem to like it because the images were static versus the really dynamic digital images that are available through DR. Also, the CR systems weren't giving the departments we visited any real efficiency improvements as far as patient throughput. If anything, CR seemed to slow them down.

Another factor was cost, especially since we were looking to convert so many rooms at once. Each DR system averaged about $200,000 which seemed fairly reasonable compared to other technologies.

All in all, the decision between CR and DR was a no-brainer. The fact that we could see more patients using DR than we certainly could using traditional x-ray systems or even CR, made it a really easy choice. In fact, to accommodate the upswing in patient throughput, we've had to install three additional exam rooms in our largest office.

After a thorough evaluation of the DR systems that are out there, which involved our x-ray techs, in January of this year we began installing four Swissray ddRModulaire units along with the company's dOd-HD-16 Detectors. The final unit was installed in July.

Our general reasons for choosing this system were:

  • Ease of use (less wear and tear on techs because there is very little overhead movement.
  • 90 percent of the procedures can be done using upright positioning.
  • Lower radiation dose for patients, which pleases them.
  • Images available in three seconds
  • For the physicians, the image are quickly available via hardwired viewing stations, via laptops, or even through wireless tablets if the physician has one.
  • Ninety-five percent of our images are taken with patients standing up. This also speeds up the process. There's not a lot of patient movement.
  • The Swissray unit cost was significantly lower and saved us costs equivalent to of a full DR room.
  • Swissray offered us local service personnel.
  • The system has no overhead crane unit which can really extend install time.
  • The Swissray unit can be installed over a weekend.
  • The system came with Ortho View software, which allows you to do some viewing even without a powerful PACS workstation.<>
  • All the turning of the unit can be done by using a remove control, thus less wear on the technologists.

Concurrently we sat down and considered the PACS portion of our plan, which was a decision we made separately from the x-ray equipment because we wanted to have flexibility. After a review, we chose to go with the StorCOMM AccessNET system which was installed in March.

Technology with a history
Another reason we chose Swissray is because it is proven technology that has been around a long time. Also, they provide very good maintenance which includes a remote diagnostic tool through which they can remotely diagnose system issues and can fix them before you even know they exist. Uptime is very important and it's essential to have a system that is reliable.

Gains in efficiency
We perform about 2,000 studies a month. Since we began adopting DR, our productivity has risen approximately 10 percent. However, we are not completely installed and so we expect that this percentage will rise significantly in the coming months once the systems are fully implemented.