Success Stories: DR and CR Case Studies

The creation of a digital imaging world continues to gain momentum as more and more facilities replace their conventional X-ray units with digital radiography (DR) and computed radiography (CR) systems.

But eliminating film comes at a steep price, depending on the system chosen, and facilities on a tight budget must decide if the productivity gains and other less tangible benefits justify the cost of the high-priced conversion.

Facilities that have made the transition, from recent converts to facilities long used to life without film, say the conversion is worth it and necessary to stay competitive — if done right. Even at facilities that have not yet quantified digital’s benefits, radiology managers say they can tell the advantages outweigh the hefty price tag. And for those who have crunched the numbers, the results speak for themselves.

At a cost of $250,000 to $500,000 for a DR system and $100,000 to $200,000 per CR system, creating a digital environment is a big commitment. For RadNet Management Inc. (Los Angeles) converting each of its 40 imaging centers to digital and networking them together is a primary goal because of the benefits digital brings the company, says John Crues, M.D., RadNet’s medical director. About one-half of the centers are already digital.

The biggest advantage is increased productivity, he says, especially considering that radiology procedures are growing by about 20 percent a year in California. Switching to digital allows the facilities to keep up with increasing patient volume, but with fewer systems and fewer employees.

“We get a four-fold improvement in throughput with the DR system; about a three-fold improvement in throughput with an automated CR system; and about a doubling in throughput if we have a CR cassette system,” Crues says.

For example, at Orange Imaging, two traditional X-ray rooms used to image about 60 patients a day. After RadNet converted those two rooms to one digital room, that one room now images 120 patients a day. At another site in Beverly Hills, RadNet converted seven traditional X-ray rooms to three digital rooms and increased procedure volume by 30 percent. Not only are fewer than half the rooms keeping up with the increased volume, but the facility is doing it in less time, shortening the day from nine hours to six hours.

The increased productivity also translates into happier patients, decreasing wait time by 50 percent.

Increased productivity is only one benefit, he adds. Without the expense of processing and handling films, operating costs have dropped too. Reduced image-handling time allowed RadNet to decrease its number of employees by 30 percent.

Crues says a less tangible but valuable benefit is RadNet’s ability to attract technologists during the nationwide tech shortage by offering them a modern, fully-digital work environment.

Opting for DR
For many facilities, going digital is not the question. Deciding between DR and CR becomes a more important issue. At more than twice the cost, DR remains out of reach for many. But those with a DR system say they receive more than twice the benefits.

“With DR, the capital expense is so much higher, but the throughput is higher so there’s a wash there,” says Crues. “We also think the image quality is so much better with a DR system. So if it’s a busy, high-end location, we prefer to go with the DR system. If it’s somewhat less busy, than we tend to go with a CR system.”

Alix Vincent, M.D., chairman of the radiology department at Riverside County Regional Medical Center (Moreno Valley, Calif.), says he prefers DR to CR, but that CR plays an important role in the hospital. Riverside County acquired a DR unit in June 2000 and has about 10 CR rooms, all of which are tied into the hospital’s PACS.

Because the hospital opened as a fully digital facility, Vincent says he cannot directly compare the benefits of digital over film at Riverside County, but he says DR’s increased productivity over CR are evident. Because the DR system eliminates plates and CR processing, patient throughput increases, he says. But just as important, Vincent adds, is the improved image quality.

But Vincent says no filmless hospital could function without CR. “You can’t get away with not having CR for portables or trauma,” he says. “But if I could have my way in a perfect world, all the CR units that I have I would replace with DR — except for the ones that absolutely have to be CR.”

David Workman, director of radiology at The Methodist Hospital (Houston), says his hospital also plans to replace CR with DR systems as the budget allows. “DR is the key to an increase in productivity,” he says.

To prove that, The Methodist Hospital conducted a study in collaboration with GE Medical Systems (GEMS of Waukesha, Wisc.) to quantify the productivity and cost of DR, CR and film. By comparing the throughput of the hospital’s chest DR system, cassette-based CR chest imaging system and conventional two-view analog film systems, the hospital found that DR reduces exam times by more than 60 percent over both CR and film.

According to the study, The Methodist Hospital timed all chest exams from the patient’s arrival in the exam room until the patient was released. DR took less than 2.5 minutes compared to film’s 6-minute and CR’s 7-minutes exam times, thereby reducing exam times by 62 percent over film and 67 percent over CR.

Although the hospital found that the CR exams took nearly a minute longer than conventional film, the time difference was due to the use of an automated, cassetteless film-based site that was docked to a 2-minute processor. So that while the CR process contains many of the same steps as conventional film, the film process in this case did not require the routine cassette-handling and darkroom tasks.

Despite the longer exam time, CR jumps ahead of film in productivity once the images are digitized. The hospital found that film required 169 minutes to be available for radiologists to read; digital images were ready within two minutes, a 98 percent reduction in time. “The real advantage of CR is once you put the image into a digital format, it’s immediately available to the referring physician,” says Workman. “You can immediately share it with multiple users.”

But Workman says that CR is more expensive than film because the plates must be replaced after about 1,000 exposures. DR, on the other hand, will save the hospital money, he says. By comparing exam times, labor costs and supplies, the study showed that a facility conducting more than 13,500 exams per year could expect to save nearly $100,000 a year by using a DR system in place of a film-based system. That cost did not factor in the initial capital expense or upkeep of equipment. According to GEMS, the same savings apply to CR, again without factoring in equipment purchases or upkeep.

Choosing CR
Although CR does not equal DR in productivity, its smaller price tag makes it a valuable option.

Fujifilm’s FCR 9502 CR system

“The smaller facility or someone who wants to phase into PACS would certainly find benefit from using CR,” says Workman. “You start with CR and as the equipment life expectancy ends than you replace it with digital radiography. That’s what we did here.”

Peggy Wollnick, radiology systems manager at North Kansas City Hospital, says that is what her facility plans to do. The hospital has a room ready for DR, but will wait until next year to purchase the system. Instead, the hospital recently installed eight CR units and a PAC system and has been filmless for about three months.

Although the hospital has not been digital long enough to study the impacts, Wollnick says they have seen many benefits, particularly in the critical care areas. Efficiency has increased because techs and physicians have instant access to the images throughout the hospital; patients are happier because techs do not leave the room to process images; and techs perform fewer repeat exams, saving time, money and radiation exposure to the patient.

Just a few months into the conversion, Wollnick says the transition has gone well with 98 percent of the physicians embracing the change. The other 2 percent, she says, are less computer literate and prefer hard-copy film. But all of the physicians seem to agree that image quality has improved. “The images sparkle,” Wollnick says. “It makes a huge difference.”

Florida Hospital Celebration Health (Celebration, Fla.) opened in January 1998 as a filmless hospital. At that time, CR was the only digital option, says Sally Grady, director of Celebration Health’s imaging center, and they have been so pleased with CR that they have no plans to obtain DR. The hospital has two CR systems that perform about 500 exams per week. Celebration Health is part of Florida Hospital’s network of six campuses and 13 medical centers in central Florida.

“There are some [DR] systems out there now, but I still think we have to wait to see if it’s going to be proven technology and see how much faster than CR it really is,” Grady says. The Florida Hospital East Orlando location is planning to test both a CR and DR system in its emergency department.

Grady says the CR systems at Celebration Health make that facility 25 percent to 40 percent more productive than the film-based imaging center she oversees at Florida Hospital Kissimmee, a similar-sized hospital.

The productivity also comes at a reduced cost. Grady says CR has reduced the hospital’s operating film cost by 50 percent. Although the CR systems are tied into a PAC system, Grady says the hospital is not completely filmless. In part because the orthopedic surgeons and neurosurgeons still prefer viewing films, but primarily because of the hospital’s proximity to Walt Disney World’s Magic Kingdom. Two miles from the tourist hotspot, 70 percent of Celebration’s emergency department patients are visitors, who frequently must take film images home with them. But Grady adds that more and more of those images are being burned on CDs, reducing the cost from about $2.00 per film to just $1.25 for a CD full of images.

Staff costs also are reduced with CR, Grady says. In 2000, Celebration Health performed just over 22,000 CR diagnostic exams with 12.5 FTEs. At Florida Hospital Kissimmee, nearly 24,000 film-based exams were done, but 15.6 FTEs were needed. Celebration Health used 20 percent fewer employees to perform just 8 percent fewer exams.

In addition to fewer techs, Grady says a digital hospital requires fewer clerical employees because they are not needed for film handling. “You don’t realize that [savings] right away, especially if you’re converting from film to digital,” Grady says. “There’s still a lot of film handling that’s required until you have more studies in your online archive.”

Although clerical staff is reduced, technical support staff is a necessary addition to keep the system running. But Grady says that the cost is minimized at Celebration Health because it shares four technical support employees with Florida Hospital’s network of hospitals.

“Our goal is to be cost neutral over the life of the equipment,” says Grady. “We feel that the benefits that we’ve achieved by having PACS and CR have been well worth the cost of the system. Some of those benefits are very hard to put a dollar figure on.”

One of the most important intangible benefits, she says, is the hospital’s competitive advantage with referring physicians. Because Florida Hospital facilities are networked together, physicians can access images taken at any location through the Internet. Referring physicians no longer have to go to the hospital or wait for images to be retrieved. Physicians also can teleconference with radiologists. Both physicians can manipulate the images in real-time. Most physicians also can access images at home, frequently saving the on-call physician a trip to the hospital.

The network also gives the hospital an advantage in report turnaround time, Grady says. Two years ago, radiologists at the main campus began 24-hour coverage. Now hospitals route images to a radiologist around the clock, dramatically reducing the hospital’s reporting time, especially for patients coming to the emergency department at night.

For Grady the choice between DR and CR is easy. “DR is a contender, but right now DR is so expensive,” she says. “For the cost of one DR room, I can pretty much take an entire medium-sized department filmless [with CR].”