Who in radiology has not heard the mantra?
If you want to stem film loss — go DR. If you want to cut department costs — go DR. If you want to increase patient throughput and department revenue, then by all means — go DR.
Anyone who has not become aware of at least one of the above justifications for DR must be cocooned in a dark room, developing X-ray film. (Aha! Yet another reason to go DR!)
Going DR can mean a large investment of time, money and resources in hardware, software and technological configurations. Generally speaking, a “make over” of that magnitude is absorbed more easily by giant healthcare corporations, well-ensconced university medical centers and extensive hospital networks.
But what about the independent, unaffiliated or oftentimes smaller facilities of the radiology-service sector — freestanding imaging facilities? When it comes to going digital — do they or don’t they? And if they do, how do they make it work?
One clinic’s story
The Kirklin Clinic of Birmingham, Ala., wrestled with the kind of “problem” other clinics crave: an abundance of customers. An outpatient facility with its own 11-room diagnostic radiology section — six of which were dedicated orthopedic rooms — Kirklin services one of the city’s more successful orthopedic practices. It also is affiliated with the University of Alabama (Birmingham), which helps keep referral volume high. In fact, the number of patients referred to Kirklin for muscular-skeletal studies increased an average of 5 percent each year the last three or four years. In 2000, the center logged 106,000 to 110,000 studies.
But as those growing numbers of patients checked in, they found themselves waiting up to two hours for an X-ray. And referring physicians — mostly orthopedics, neurologists and neurosurgeons — began demanding faster turnaround.
“The last time-management study we had done, our patients were coming in on Tuesdays, Wednesdays and Thursdays between 9:30 a.m. and 2 p.m. at a pace of one a minute, so they were moving in pretty quickly; the front desk was just being overwhelmed with patients,” begins David Atkinson, Kirklin’s former manager of radiology, who recently left Kirklin for medical equipment distributor PPX Imaging Inc. (Birmingham). “Then it would be 3 o’clock in the afternoon, and there was nobody coming in. Our waiting room was empty, and three hours earlier it was standing room only.”
First-round attempts to alleviate those crushing patient traffic jams by appealing to referring physicians to expand the hours they saw patients to mirror Kirklin’s 8 a.m. to 5 p.m. hours of operation, met with limited success. Patients continued to pour in between 9:30 a.m. and 2 p.m.
Clinic staff then determined they had two choices: to increase the center’s capability by building additional X-ray rooms or to increase its utilization rate, which Atkinson says was already “90 percent-plus” during the four-and-a-half-hour blitzkrieg.
“But in order for us to build more rooms, we had to go out and capture more space, which meant more rent for us; we had to spend money for the renovations; we had to spend money for the equipment; and we were going to have to spend money for the technologists to man those rooms; and other than that, between 8 and 9:30 and between 2:30 and 5, [those rooms] were going to sit idle just like most of the rest of the rooms,” recounts Atkinson. “And we were not capturing any more revenue. This was revenue that was going to be there anyway. The only good point was we were going to be able to turn patients around faster between those hours.”
Dismissing any physical expansion as too costly, clinic staff members decided to boost patient turnaround time by turning to technology.
They looked into computed radiography (CR) but concluded that having to process CR plates would do little to improve patient throughput. Flat panel-based DR, on the other hand, held promise.
“We thought DR would enable us to turn around exams faster, but we weren’t sure what the exact increase would be,” Atkinson recalls. “We felt sure it would be a 20 percent or 30 percent increase in turnaround, because all you were doing was positioning the patient, taking X-rays and then the patient was gone. Also, by having those [images] online, in a network, you would be able to ship those back to the ordering physician and be able to get him what he needed quicker, too. So that was the direction we went in.”
Last fall, Kirklin purchased a flat-panel digital retrofit system — the StingRay DR from InfiMed Inc. (Liverpool, N.Y.). The StingRay DR, with its universal bucky replacement system, uses a Trixell S.A.S. (Moirans, France) Pixium 4600 flat-panel detector. The list price is $225,000.
“The existing equipment in the room was fairly new, I mean, it was three or four years old,” Atkinson explains. “So it was less expensive and easier for us to remove the bucky tray and put in the new InfiMed system. It was a beta site for them, so it was an evaluation period for all of us. But it worked out.”
To most everyone’s advantage — apparently.
Atkinson points out that the technologists, who embraced their “new toy,” had their images six seconds after exposure. As a result, patients were up, out and on their way in short order.
At this point, images are still printed to film for referring physicians, then immediately archived in a PACS (picture archiving and communications system) connected to the university.
“What we were trying to do — and our total justification — was to get a patient in the exam room, get an image taken and get the patient out as fast as we could,” Atkinson emphasizes. “And that seemed to work because you were not having to take film from a cassette, run it to a processor and wait 90 seconds for the film to develop, and then check it out, because you were checking an image only six seconds after exposure. They [patients] were not waiting nearly as long as before the system was installed.
“But you’ve got to remember: This was just one room out of the six. We didn’t turn things around overnight,” he says. “Our hopes were that we would never have to convert all six rooms — that you could do three rooms and probably accomplish the same you were doing in six and have the other three rooms to help things along. The other three rooms were probably going to be converted to CR at some point in time, but that was further down the road.”
DR from the start
“Further down the road” had no place in Pacific American Medical Service’s (LaJolla, Calif.) business plan.
Anthony Brown, president, CEO and owner, opened the 800-square-foot freestanding imaging facility with CCD-based DR in place from day one, in September 2000. The center performs 15 to 20 studies a day, five days a week, using Swissray International Inc.’s (New York) ddrMulti-System, a C-arm configured system incorporating CCD (charged-couple device) technology. It has a staff of three: Brown, a technologist and a facility manager.
Brown’s Medicare-designated IDTF (Independent Diagnostic Testing Facility) is an offshoot of Pacific American’s original business started five years ago: contracting for C-arms in operating rooms (OR) at outpatient surgery centers. The company continues that side of the business with 15 C-arms from various manufacturers serving approximately 40 accounts throughout California, from San Francisco south to the border with Mexico.
As a result of the OR contracting business, Brown, a U.S. Air Force-trained technologist, already trusted C-arms and CCD technology. His choice of new imaging equipment, then, was a natural. Or, as he put it, “When I was presented with the opportunity to do a freestanding facility to support the physicians in this region, I immediately went with the technology I was comfortable with.
“I know how to utilize the C-arm configuration for productivity. I can run a C-arm quicker than I can run a freestanding X-ray tube and a piece of film,” he declares. “That was very important to me, too. Not having to handle cassettes of any type, whether they be film or CR cassettes. It makes productivity so much higher.”
Another factor in Brown’s comfort with the technology was his belief that that CCD approach to DR benefits the patient in the form of lower radiation dose.
“With a CCD camera, you can do anything from soft-tissue studies all the way to deep orthopedic-type procedures with the same shot, just by changing the parameters,” he details. “Again, this is where the expertise comes from using the C-arms, being able to manipulate your image by using different filters and settings on the program to give you different types of X-rays. Your repeat rate goes down a lot because you can salvage an X-ray by using different parameters, so your dosage to the patient dose down in the form of fewer repeats and in the form of not needing as much X-ray to produce an image as with regular film.”
Since setting up the ddrMultiSystem, Swissray and partner StorComm Inc. (Jacksonville, Fla.), which is providing integral integrated connections with its CIMS (Clinical Image Management Systems) software, have been working in concert with Pacific American Medical Service to ensure that the center gets the most out of its installation, he states.
Brown declines to reveal the cost of his installation, intimating only that the hardware alone ranks in the ‘half-million-dollar range” and that required software and networking components carry a much larger price tag.
“Everybody is fascinated with the technology, but making it work practically is a whole ‘nother ball of wax,” he confides. “Showing somebody a digital X-ray — it’s cool, it’s great and it’s high-tech, but delivering that X-ray is a big problem and it presents different challenges to try to make this system work.”
Currently, the facility operates within a LAN (local area network) with plans to expand to a WAN (wide area network). However, it also prints film for referring physicians, and, every two weeks, it burns CDs by doctor, with one copy for the physician and one for Pacific American’s own files. That assures physicians access to their own images, Brown notes, while also satisfying HIPAA (Health Insurance Portability and Accountability Act) regulations regarding off-site storage.
“We deliver [images] through access to our server and by providing them with paper copies for instant referencing,” he offers. “Some of the doctors are very wary of broadcasting images or making them accessible over the Internet and the World Wide Web, and there are not enough people out there who can guarantee security and authentication.”
Brown admits that he opened the center knowing full well that delivering images would be a challenge, yet he proceeded, undeterred.
Some doctors are tiptoeing toward digital, he observes: They have simple PCs and flat-panels in their examination room that they use to query the Pacific American server, pull up an image and use it as a reference point as part of their explanation to a patient. But they cannot dictate off those flat-panels and they cannot diagnosis off the paper copies, so Pacific American offers its core of referring physicians a reading station for diagnostic purposes.
While Brown anticipates that his work volume will grow, he discloses that the imaging facility is able to exist with fewer studies — at least for now — because he has the backing of Pacific American’s C-arm contracting side. “I knew what I was getting into as far as being able to calculate the financial part of it, how many cases I needed to do and so forth. We worked up the numbers, and we were close enough that I decided to go ahead and do this.”
Meanwhile, when occasions arise for “special requests” that reap straight service fees for the center, businessman Brown pounces.
Some Saturdays when the facility is closed to patients, Pacific American has X-rayed laptops, artwork and gemstones for insurance purposes and identification. One circumstance, in particular, stands out in Brown’s memory: A tire engineer working for a law firm X-rayed steel treads in blown Firestone-brand tires.
DR and CR in harmony
The Golden State is proving to be a golden opportunity for one company’s decision to take full advantage of the DR spectrum.
RadNet Management Inc. (Los Angeles, Calif.) about a year ago added DR to two of the 40 freestanding imaging sites the company owns and operates throughout California. The two, like several of the centers under RadNet’s purview, were imaging patients with CR systems from Fuji Medical Systems USA Inc. (Stamford, Conn.). Here, the new DR pieces are complementing, not replacing, the CR equipment already installed.
“There are several reasons why we went with DR,” opines John Crues, M.D., RadNet medical director for five-and-a-half years. “One is, in our model, once you have all the information technology in place, we find that DR is a faster system than CR; we can do more patients per unit time. Another is that the radiologists prefer, slightly, the image quality with DR versus CR.
“For a fully digital environment,” however, he insists, “you require CR because there are no fully DR-developed fluoro systems on the market at the current time. To do fluoro and some other forms of specialty X-ray examinations, you have to have the ability to use cassettes. In developing the digital department, the department first has to do CR, then we do DR in those sites that are very, very busy — where we can not only keep our CR system busy but we can benefit from the increased input of a DR system.”
RadNet considered several vendors, and decided on equipment from Canon Medical Systems (Irvine, Calif.). In short order, the “very, very busy” Orange (Calif.) Imaging Center took delivery of the CXDI-22 with a universal arm for both supine and upright studies, while the equally busy Tower Imaging — Wilshire (Beverly Hills, Calif.) moved in the CXDI-11 chest X-ray unit. The CXDI-11 has since been transferred to the RadNet’s Healthcare Imaging (Riverside, Calif.) center.
The CR equipment at those sites includes Fuji’s FCR 9501ES upright CR reader, a model that integrates the imaging plates into the Image Reader and allows the user to eliminate either bone or soft issue anatomy with an “energy subtraction” feature; and the FCR 9502 CR Table.
Crues says the Orange Imaging Center DR system handles an average of 100 studies a day, but he suggests that the number of patients a freestanding facility images depends on available volume.
“If you only have 60 patients a day then you are only going to do 60 patients a day; if you have 200 patients a day and your system can do 120, then you will do 120 patients a day,” he expounds. “So it’s not quite [comparing] apples and oranges, but, in general, we feel the DR system can have a 20 percent increase in productivity over the CR system. But that depends on the kind of CR system you have.”
Like Kirklin and Pacific American Medical Service, RadNet’s two DR sites still print film for a majority of their referring physicians. But, Crues adds quickly, “Those films do not have to be tracked, and they also don’t have to be schlepped around the imaging department. And since the radiologist doesn’t see those films, it doesn’t impede the efficiency of the center itself. The major cost of film that a lot of people don’t recognize is the inefficiency of the operation of a center if one has to use film as a primary medium by which we communicate the image information internally within the enter. We eliminate that cost,” he asserts, by the fact that all RadNet centers connect to a corporate-wide PACS. The corporation’s 35 employee-radiologists read those digital images. The company also outsources another 35 or so radiologists to local radiology departments.
Orange Imaging’s and Healthcare Imaging’s referring-physician population runs the gamut: In outlying areas, most do not have access to the Web. For those physicians gearing up for online transactions, RadNet is experimenting with a system that permits them to log in with proper security and download images using a standard Web connection. In tony Beverly Hills, where Crues says the hospital mandates that all physicians be on the Web to receive reports and lab information, every office is connected.
One problem RadNet encountered when first going digital — one that lost them many referrals — had to do with X-rays being printed on smaller sheets of film than physicians were accustomed to and would accept. It took a year working with vendors — and testimonials from satisfied patients — to correct that.
“Because of that episode, the digital X-ray developed a negative connotation with our referring sources,” remembers Crues. “A lot of academic centers were printing to smaller sheets of film and they were able to get away with it because it is not as competitive an environment, but we got into trouble initially with that. That has pretty much been corrected, but there is still a residual of concern of not having traditional film-based X-ray among a lot of referring physicians.
“One of the things that got us past our initial problem is that their patients loved it so much that they demanded to go to the center. That really helped us.”
Crues knows patient demand helped lure ordering doctors back to RadNet’s digital centers. He also knows that adding DR to its CR has helped RadNet overall. He has the numbers to prove it: The company achieved a 30 percent increase in volume in each of its last three years of operation while costs remained flat.
“We have had almost double the volume over the last three years, but our costs have stayed almost flat because we have been able to save a tremendous amount by going into digital imaging,” he concludes. “And we think, in the future, there will be even more savings as we use the Internet more to transfer information to physicians.”
The A, B and C of going DR
Mention going DR and any number of pundits will weigh in with advice, anecdotes and admonishments. But A(tkinson), B(rown) and C(rues) come to the discussion with the perspective of those who have fought in the trenches, so to speak.
• Mind — and mine — your network of referring physicians. Atkinson makes clear that “referring physicians exert a lot of influence on whether the system will work.” He also cautions that going DR is an expensive proposition and the decision should be a group one, even including referring physicians, when possible.
• Learn all you can. “The education process is a big part of this,” suggests Brown. “You do have to have a background in both X-ray and computers in order to make this work, otherwise you would have to staff so many people to keep it running. If anybody is interested in making this happen, they have to make sure their manager or their technologist can troubleshoot a networking problem, can troubleshoot a Windows 2000 problem, a cabling problem, on top of the X-ray part. The more education one person can get in both the computer aspect and the X-ray aspect, the better.”
• Don’t put the cart before the horse. “If people want to go into digital imaging the way that we think makes sense, they have to have a RIS (radiology information system) and they also have to have a PACS, so there are a lot of costs up front that they have to have in place before it really makes sense to go into digital X-ray,” recommends Crues. “People tend to do this backwards, and I think that’s a problem that digital imaging had at the beginning: People were not putting all the pieces together first and then they were finding that instead of streamlining their operations it just added a lot of headaches and difficulties to the operation that are inherent in a new technology, but they did not get any benefits from it.
• Don’t be afraid to go DR. Your business depends on it. Predicts Crues: “I don’t think any large X-ray facility is going to be able to prosper over the next 10 years unless they convert to digital.” 
