|Danny Meadows, Brookwood Medical Center, Birmingham, Ala
Toward the end of a 5-year phase-in of a picture archiving and communications system (PACS) at Brookwood Medical Center, Birmingham, Ala, Danny Meadows, the administrative director of imaging services, received disappointing news: there would not be enough money in the upcoming budget to permit final implementation of the filmless image distribution system in accordance with the planned timeline. The bearers of these tidings told him that it might even be as many as 4 more years before sufficient capital would be available for him to acquire the final PACS components. That was unacceptable to Meadows, an architect of the PACS implementation plan.
Searching for a solution, Meadows hit on the idea of using an Internet-based application service provider (ASP) for the archive portion of the PACS project. He evaluated the financial variables involved and found that using an off-site ASP would save the department enough money to pay for the remaining PACS elements right away, thereby permitting completion of the rollout in keeping with the original schedule. He presented his proposal to the hospital’s key decision makers, who gave it their blessing.
At about the same time, the imaging services department determined that it urgently needed to replace two outdated radiography suites in the hospital’s emergency department. Since the purpose behind bringing aboard PACS was to transform the enterprise into a filmless environment, Meadows investigated the potential for replacing the emergency department’s analog-film radiography machines with digital versions, either computed radiography (CR) or digital radiography. After careful consideration, his department opted for digital radiography, finding it superior to CR in its ability to deliver substantive operational efficiencies.
At this point, further difficulties were encountered. Meadows hoped to be able to acquire the digital radiography machine by including it as an expense item attached to the ASP budget. “The funds allocated for the ASP solution included enough money to purchase various hardware and software extras that were good to have, but not absolutely essential,” Meadows says. “The ASP budget also was based on a certain level of staffing and on the need for a certain number of supplies of different kinds. I thought that it might be possible to do without some of those extras, and to revamp the staffing levels and supply scenarios so as to carve out sufficient savings to be able to pay for the digital radiography system at that time, avoiding the need to wait for it as a conventional, separate line-item purchase.” Meadows came close to finding the savings that he needed, but not close enough to satisfy the hospital’s ironclad mandate of covering every dollar of the digital radiography equipment’s cost with one full dollar of savings from the PACS ASP. Nonetheless, all was not lost.
Brookwood Medical Center is a 586-bed acute care facility owned by a for-profit business, Santa Barbara, Calif-based Tenet Healthcare Corp (which, through its subsidiaries, owns and operates 114 acute care hospitals having 28,166 beds). The company also employs approximately 110,000 people serving communities in 17 states, and serves its hospitals from an operations center located in Dallas. Brookwood Medical Center is not Birmingham’s highest-visibility hospital (that distinction belongs to the University of Alabama at Birmingham Medical Center across town), but it is, without challenge, the busiest surgical facility in the entire state. That keeps staff busy in the imaging services department, which generates up to 150,000 general diagnostic and interventional studies annually. “We have a full array of imaging modalities,” Meadows says.
In early 2000, the department decided that the time had come to replace its two radiography suites in the emergency department. “Those machines were at the end of their useful service life,” Meadows says. “The rooms were each about 12 years old. We had gotten a lot of use out of them, but at that point, the equipment was breaking down a lot and service was becoming harder to obtain.”
The discussions concerning what to do about those two rooms took place against the backdrop of the department’s conversion to a full PACS. “We had some debate as to whether we wanted to replace the old radiography equipment with CR or digital radiography,” Meadows says. “After making a number of visits to sites that had both types of equipment, we decided digital radiography would allow us not only to meet current needs, but also to accommodate expected growth without having to add extra staff or equipment in the emergency department.”
Meadows and his staff may have been eager to lay their hands on digital radiography equipment, but the same could not be said about money managers at the facility and those higher up the chain of command. “They were more reserved,” Meadows recalls. “That’s not because they were not sold on digital radiography as a technology. In fact, they were, since they had been looking into it themselves, and they recognized its potential. Their reservations had to do with cost. The direct radiography system that we were interested in acquiring was about 50% more expensive than a traditional analog radiography room in an emergency-department setting.”
Meadows continues, “Tenet Healthcare Corp has very strict return-on-investment (ROI) guidelines for each type of capital expenditure; if the ROI does not meet the guidelines, then the request is not likely to be approved. That is perfectly reasonable. After all, we have a limited capital base for investments, so there has to be a high level of scrutiny applied to every acquisition request. We want to make sure that we are getting the best for the amount of money spent.”
Not eager to jump through the various hoops of the purchase-request? justification process, Meadows thought that he might be able to circumvent it by incorporating the costs of the digital radiography system within the budget that had been already approved for the PACS ASP archiving system. When it became obvious that Meadows was not going to be able to come up with enough dollar-for-dollar savings to accomplish that, he resigned himself to the idea of digital radiography as an acquisition that would have to wait for another year, at the very least.
That weighed heavily on Meadows. He had hoped to work digital radiography into the ASP budget not only for the financial advantage, but because also it would afford a desirable degree of protection against technology obsolescence. “Our ASP vendor had signed an agreement with us to ensure that the relevant storage and network components would be regularly updated as warranted by improvements in technology,” he says. “We had been in PACS long enough, by that point, to know that, within 2 years of purchasing a component, you are already looking at obsolescence. I wanted to avoid that with the digital radiography system, at least insofar as image storage and network infrastructure were concerned.”
Suddenly, opportunity knocked. Meadows obtained word from the financial office that both the hospital and the corporation had performed better than expected during the first three quarters of fiscal year 2001, and the still-to-be-completed fourth quarter would be similar. As a result, additional capital was available to the imaging services department, should there be equipment that the department would like to acquire as a last-minute addendum to its general budget.
Meadows lost no time in putting together a proposal for purchasing the digital radiography system with some of that found money. Still, he had to justify the cost. “To come up with the justification, we first took our current volume of studies and applied to it a projected rate of growth based on an extrapolation of the actual growth that we had seen over the prior 2 years,” he says. “This let us come up with a reasonable forecast of how many examinations we would be doing in each emergency-department imaging room in the years ahead. We then determined the expected reduction in costs for film and supplies that would result from having a digital radiography system rather than an analog radiography machine. We also factored in savings that we knew would result from the improved throughput that the digital radiography system would introduce.”
Meadows cannot disclose any of the financial numbers used in those calculations, but he does reveal that the efficiency that he expected to gain from digital radiography allowed him to predict as much as a 40% reduction in staffing requirements in the emergency department. The purchase request that he then wrote was submitted first to the finance office of the hospital. Decision makers liked what they saw and approved it, after which it was sent to the corporation’s regional headquarters for review. It won approval there, as well. Finally, it made its way to national headquarters and was approved once more.
Although the purchase request had been granted, there was one catch: it was May 1, 2001, and the digital radiography system had to be installed and fully operational by May 31, 2001, the last day of the corporation’s fiscal year. “Becoming operational a day beyond that deadline would have landed us in a lot of hot water,” Meadows says. “We basically had a month to pull out the old room, renovate it, and get the new room installed.” By the end of day on May 1, Meadows already had issued a purchase order. Once the equipment arrived, 3 weeks later, it was installed in just 3 days.
“The equipment pretty much rolled in and plugged in,” Meadows says. “It was probably one of the easiest installation jobs that I had ever seen for a piece of equipment of that level of sophistication.” Part of the reason that the installation went so smoothly was that the department was concurrently installing its ASP connections. This meant that the ASP vendor had technical staff present at Brookwood Medical Center, and they were available to assist the digital radiography vendor with some of the network connections.
The other reason for the rapid installation was that the digital radiography system was engineered to meet current Digital Imaging and Communications in Medicine standards and included interface software that vastly simplified the task of connecting it to the network and PACS. By May 31, Imaging Services was generating digital radiography studies without a hitch, Meadows reports. All requirements were satisfied; everyone was happy.
The system purchased was made by Swissray International and is officially known as a direct digital radiography (ddR) device. Unlike other types of digital radiography systems, this one employs a novel, yet highly reliable, detector technology that allows operators to take exposures at a remarkably fast rate of once every 5 seconds.
“The detector system contains an array of four charge-coupled device cameras that record information in digital form from a scintillator,” Meadows says. “The scintillator’s job is to convert radiation to light that the cameras can capture. The images produced are very high in quality and they allow us to see soft tissue, not just bone.” He adds, “Our Swissray ddR came as a package, and that held a lot of appeal for us. It included a conventional generator, a Health Level 7 interface to the radiology information system (RIS) for work list management, and an interface to an emergency department workstation for soft-copy. The system also featured a bar-code reader. That allowed our hospital information system or RIS to generate a bar-code demographic label that we could then use with our work-list management software. The technologist could scan that label, which automatically would feed all the demographic data into the system. That way, the technologist would not have to type in anything.”
Also contained in the package was a color monitor for quality-control checks by the technologists. “Each image, before it is sent across the network to the radiologist for interpretation, is reviewed for quality and correctness by the technologist,” Meadows explains. “If the image is OK, the technologist hits the send key. The system then simultaneously routes a copy of the image to both the emergency-department workstation and the PACS. This approach allows images to arrive at the workstation more quickly than if we were to send them first to the PACS and then back out, from there, to the emergency-department workstation.”
Meadows says that the ddR system has received rave reviews from the staff. “The technologists prefer ddR so much that we can scarcely persuade them to use any other rooms for radiography work,” he reports. Who can blame them? According to Meadows, the Swissray system increased productivity by about 300%. “With ddR, we have been able to do, in one room, the work that formerly required two analog radiography rooms,” he says. The productivity increase is attributable to more than the rapid-fire rate of exposure. It is also due to various features of the machine; these include a motorized, programmable C-arm that automatically swings the image-making components into precise position and a specially designed multipurpose table that is rigid enough to ensure that there is no distortion of images, regardless of the severity of the shot’s angle. “One of the things that is amazing about this system is the ease of taking a picture,” Meadows says. “You can image a patient who is standing, seated in a wheelchair, or lying on a table. It is so flexible that setting up your shot is almost effortless.”
In addition to the ddR system, the department also purchased a few CR machines in order to perform portable radiography. Meadows says that the CR units do not compare favorably with the ddR. “In a trauma setting where you are doing multiple procedures, it is disadvantageous to have to handle cassettes, as is the case with CR,” he says. “It is a lot slower to use CR as a result. By contrast, with ddR, we make the exposure, and it comes up on the screen almost immediately.”
At some point in the future, a second ddR system will probably be acquired. That one, Meadows says, will almost certainly be deployed in the imaging services department’s core area and will be used for general-purpose radiography procedures. This contemplated installation will handle both inpatient and outpatient work. As in the emergency department, this next acquisition will allow the department to consolidate suites. “One ddR system will replace two existing rooms,” Meadows says.
In retrospect, Meadows wishes now that he had tried harder to find some way of working the first ddR into the ASP budget. Had he been successful, the extra funds that suddenly materialized at the end of the 2001 fiscal year could have been used to purchase the second ddR, which now must wait. “Putting in both rooms at about the same time would have eliminated, for us, some headaches and hassles resulting from reliance on CR,” he explains. “We have some CR units in both our emergency department and our main department area. We came to the conclusion that, with CR, you do not really gain much of a throughput advantage. Savings were promised with CR, but we never saw them.”
Meadows concludes, “That certainly could not be said of ddR. The savings that were promised, we saw almost immediately, and they were significant savings. An examination that might take 10 or 15 minutes to perform on analog equipment is done in less than 5 now, and, we can do the same volume of work with about 40% less staffing than before. It is great technology: good for the enterprise, good for the people who use it and rely on it, and good for the patients.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.