For many hospital radiology departments planning a filmless future, the first step toward that goal is not an investment in a picture archiving and communications system (PACS). More likely, it is acquisition of a digital radiography (DR) machine.

There are two primary reasons for this choice. First, whether DR or computed radiography (CR), the technologies are not nearly as expensive as is PACS. Second, they represents a less risky and less disruptive entry level to filmless. And while the initial purchase of CR requires a smaller capital outlay than DR, the improved throughput that comes with DR is providing a compelling consideration for cost justification initiatives.

David Sack is administrative director of radiology, biomedical, and urodynamics at St. Luke’s Episcopal Health System in Houston. For about a decade, St. Luke’s operated a dedicated, plain-film chest radiography room. This unit was located in a medical tower serving as an ambulatory center.

Not long ago, the radiology department began planning to acquire a PACS, so the timing for looking into DR seemed ideal. “We were presented an opportunity to serve as a beta site for a vendor that was developing a DR machine,” Sack says. “I jumped at the chance to participate since we were at that point getting ready to replace our chest radiography room anyway.”

The DR vendor provided St. Luke’s with a unit that included a workstation and a laser processor. “Film was very problematic for us, and that’s why we were so enthusiastic about DR,” Sack says. “We would make an exposure, wait for the film to come out of the processor, look at the film, and determine whether or not it was satisfactory in terms of technique and patient positioning.

“The film would then be brought to the radiologist in the reading room. If present, the radiologist would read the film. If not, the film would be stacked to be read later. Meanwhile, the patient would usually have to go back to their physician’s office — and would be expected to hand-carry the films direct to their doctor.

“If the radiologist was not available and time was ticking away, we’d end up sending the patient back to their physician with the films unread.”

But once those unread films left the department, they often never returned, Sack adds.

“We did not have the capability of making a copy to give to the patient,” he explains. “Patients had to be given the original films.”

Now, with the DR system installed, the department outputs the image to film but has available a soft copy of each image for viewing on the workstation.

“Patients can carry the film back with them and even if a radiologist has not yet read it, it’s not a problem,” Sack says. “The radiologist can read the soft copy. And, if I need to, I can print another set of films from the stored image in the system.”

Sack notes that his DR room sees as many as 60 patients daily — a number that represents about half of the department’s daily total plain-film volume. “That relieves pressure on the other radiography and fluoroscopy procedure rooms,” he says. “As a result, those rooms now are less likely to experience bottlenecks.”


A desire to avoid bottlenecks existed as well within the radiology department at Loyola University Medical Center in Maywood, Ill. It was what recently prompted that enterprise’s imaging team to likewise investigate DR technology.

“We have a very busy orthopedic clinic that we provide imaging services to,” says Himanshu Pandya, MS, MSM, administrative director of radiology clinical services at Loyola. “Before introducing DR, the orthopedists were complaining that their patients were waiting too long to have radiographs taken. That was a bottleneck for radiology and also for the orthopedists.

“The DR unit has eliminated most of this problem. We now move one patient right after another through the room. Patient throughput has improved by perhaps 40% to 50%.”

DR found its way into Loyola’s radiology environment following a decision by the hospital’s leadership to implement a PACS.

“This gave rise to the need to convert all modalities to digital,” Pandya says.

Currently, Loyola is weighing both DR and CR and will eventually choose one as the mainstay modality. Pandya hints that DR currently holds the lead in this contest.

“CR is somewhat less expensive than DR,” he says. “Also CR allows you to easily convert most modalities to digital output. However, with DR, the throughput is better. For us, that trumps most other considerations.”

At present the department owns one DR unit — purchased new — and it is deployed at the medical center’s on-campus outpatient facility. This machine was acquired at the beginning of the year and replaced an analog chest radiography machine.

“We have seen that productivity is achieved with fewer steps because of DR,” Pandya says. “With CR, you still have processing steps that you must perform. Not so with DR. The technologists can take the DR image with significantly greater confidence that the patient is positioned correctly and that a retake will be unnecessary. That alone greatly improves throughput.”

Improved productivity also serves to temper a department’s full-time equivalent (FTE) requirements.

“The productivity gains from the DR unit have allowed us to handle more cases, but we’re doing so with the same number of FTEs,” Pandya says.

DR does, however, have limitations that can adversely affect productivity. One is a lag of about 3- or 4-second duration between the instant when the technologist activates the rotor and the exposure is made. That can make it impossible to capture exposures while working with difficult patients, Sack points out.

“I thought for sure this would be a source of complaints from the technologists,” he says. “But it has not worked out that way. That is due entirely to the skill of the technologists, who have developed techniques to compensate for this limitation.”

Another problem that has not caused as much harm as feared is the absence of an interface between the DR unit and the radiology information system (RIS).

“Because there’s no RIS interface, we have to manually type in the patient demographics to go with each study,” he says. “I was very concerned that it would take longer to type in the demographics than to take the exposure. I worried that the technologists would find using the DR machine to be a pain in the neck because of that. However, that was not the case at all. It never became an issue. I was quite surprised.”


A pleasant surprise, too, is how readily the cost of a DR room — which may range from $150,000 to $200,000 — can be justified, observes John Rego, MD, chief of radiology at Kaiser Permanente Hospital in San Francisco.

DR came to the Kaiser Permanente Hospital last December and was installed in a newly built outpatient facility. Planning for that new facility began in 1995. As originally envisioned, it would have included five radiography rooms, all employing analog radiography machines.

However, the slow pace of construction allowed the passage of enough time that viable digital alternatives to analog radiography became available. As the technology advanced, the hospital updated its plans to keep pace with the changes.

“The planned environment in the new facility went from plain film to CR and ultimately to DR,” Rego says.

When it eventually was decided to run with DR, the number of planned radiographic rooms was decreased to three.

“By eliminating the need for two analog radiography machines, we found enough savings to pay most of the cost of one DR system.”

Actually, the rooms themselves were built as planned (construction on them had already started by the time the decision was made to forego two analog machines). Consequently, the rooms sit empty.

“Had we caught the builders in time, we could have had the blueprints revamped to eliminate the construction of the unused rooms,” he says. “That would have saved us even more money, which we surely would have invested in additional DR technology, workstations, and network infrastructure.”

Currently, the hospital is exploring ways to distribute its DR images electronically to referring physicians. The most promising method involves use of Internet-based software.

“We think giving physicians access to the images on their desktop computers through a Web browser may prove a satisfactory solution,” Rego says.

A systemwide approach to the electronic distribution of images is vital for Kaiser — it will make, Rego says, much operational and economic sense, since members of the HMO are permitted to receive care in any of the 19 hospitals that comprise the Kaiser Permanente enterprise in California.

“Our patients often go from hospital to hospital and department to department, so it would be advantageous to link all these units together in a networked configuration,” he says.


Even in a networked environment where DR images are distributed electronically, there still remains a role for film.

“We’ll have to utilize film for mammography,” says Larry Kirschner, MS, director of radiology services for Hartford Hospital in Hartford, Conn. “The digital mammography systems that are on the market right now are much too expensive for a facility such as ours to afford — and we could certainly never justify that cost in light of the current low rates of reimbursement being paid by insurers.”

Apart from mammography, there still may need to be the occasional film copies produced for referring physicians outside the enterprise who are not able for what ever reason to receive and view electronic images, Kirschner contends.

“We’ll also need to keep our film view-boxes handy for looking at films that are sent to us from the outside,” he says.

Hartford’s radiology department operates mainly as an inpatient service, but expects to see growth in outpatient volume thanks to new CT, interventional MRI, and positron emission tomography modalities. The DR chest unit — a new room, not a retrofit — is located within the confines of the main radiology department in the hospital.

“Our patients tend to be quite ill,” Kirschner says. “Consequently, we had been trying to develop ways in which our technologists could avoid leaving patients unattended. DR solves this problem. With analog technology, the technologist has to walk away for several minutes to develop the film. But with the DR unit, the technologist can process the image from the examination room, never once having to lose sight of the patient.”

A challenge of DR implementation, as with any newly introduced technology, is finding ways to make physicians comfortable with the technology. At Loyola, for example, the orthopedists who were the beneficiaries of digitally produced images were not thrilled by the idea, for they were accustomed to taking their precise bone measurements from analog film, Pandya notes.

“We had to provide training to the orthopedists to help them overcome their objections to digital,” he says. “After the training, they realized how much better it was to work with digitally produced images. Now they wonder how they ever got along without it.”

Still, not every orthopedist was willing to jump on the digital bandwagon.

“For those who could not get accustomed to working in the digital environment, we have had to continue offering analog film,” Pandya says.

That is one reason that film may not completely vanish at Loyola and other institutions where at least a few physicians cling to older ways.

Sacks, meanwhile, found that the timing of the DR introduction at his enterprise served to whet the appetite of the radiologists for the still-to-come PACS.

“They have been exposed in a low-key, nonthreatening way to working in a digital environment thanks to DR,” he says. “Now they cannot wait to start working in a truly filmless environment, which PACS will allow us to establish. When PACs does at last arrive here, we will not have to go through a long, drawn out process of convincing the radiologists to give up their customary ways of working. We have buy-in already.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.