imageSize matters — even in healthcare. Don’t even begin to pretend otherwise.

Larger hospitals command bigger budgets, employ extensive expertise, enjoy positions of prominence and wield colossal clout. And have they converted to digital radiography (DR)? Most likely, or at least partially. Probably a couple of years ago.

But the little guys are now making their move.

Smaller hospitals — 250 beds and counting — have watched their bigger brothers and sisters “get the bugs out,” they’ve listened to all the “do’s and don’ts,” they’ve studied their own situations inside and out.

And a number of them are finding DR a good fit — no matter what their size.

Here’s how three smaller hospitals bought into DR.

DR arrives in Winter Wonderland
From late spring through glorious summer, the 247-bed Yuma (Ariz.) Regional Medical Center caters to its core audience of 78,000 Yuma residents. Come fall and winter, those numbers snowball to 150,000, as winter visitors — the locals call them “snowbirds” — flock to Yuma’s great outdoors. Then on Thanksgiving and Memorial Day holidays, weekend warriors swell the population count to about 250,000. Unfortunately, many of them leave their mark in Yuma Regional’s trauma unit, the result of a seductive combination: indomitable sand dunes, high-powered recreational toys and a tendency to imbibe.

“Productivity was a big factor; the increase in productivity is a definite benefit,” begins Marty Schotten, a clinical resource coordinator, a “middle manager” with supervisory responsibilities in X-ray and nuclear medicine. “And price was a factor. But our biggest factor here is service.”

As Yuma contemplated installing its first DR system, service rated high on its list of must-haves because the hospital is considered a remote community site. “There’s not another hospital within 60 miles and not another major medical center within 180 miles that is accessible for extended-care types of things,” says Schotten, who was involved in the DR decision-making process.

“We have two major vendors here. We were going to go with them because they have in-town service,” he relates. “Our original decision was to go with our vendors that we have had for quite some time, but when it came down to the delivery time we needed, we couldn’t get it, so we had to look at the alternative. We were able to get the service needs from Swissray.”

Yuma came by its Swissway International Inc. (New York) ddrMulti-System with C-arm configuration and CCD (charged-couple device) technology via Swissray marketing partner Hitachi Medical Systems America Inc. (Twinsburg, Ohio). When the ddrMulti-System was installed in Yuma’s emergency department (ED) on Dec. 15, 2000, it earned the distinction of being not only the first DR installation at the hospital, but also the only one in the surrounding area. On that same date, Yuma also rolled out a new CR (computed radiography) installation, the portable ADC Solo from Agfa Corp. (Ridgefield, N.J.), for use in a nursery program designed to handle premature infants as young as 28 weeks.

Previous to DR’s coming on board Yuma, patients were funneled to the acute-trauma emergency room or to a subacute emergency room and a newer subacute waiting area, depending upon the severity of their injuries. Now, however, all emergency patients with the exception of those requiring an IVP (intravenous pyelography) go through the ED and get the DR treatment, thus effecting a general increase in patients seen. The mere presence of DR technology is proving enough of an attraction for the change.

“We have not done a total comparison because some of the information on where we did [X-rays] previously was uncapturable. What we have seen this year over last year is an increase of 300 patients a month on average through the ED for

X-ray exams,” Schotten details. “So we are able to do 300 exams more than we did the years previous in those [acute and subacute] rooms with no change in staff. That just compares the overall number of exams the ED has ordered, and we do 100 percent of the emergency orders whether it is from the acute trauma side or from the nontraumatic side of the ED. Since Dec. 15, we have been doing about 86 exams per day on a daily average. Prior to that I would say, on a full day or a busy day, we were doing about 50 to 55. And we will have room to do more but,” he cautions, “we are fast approaching saturation.”

Yuma maneuvered the ddrMulti-System into its existing ED space without having to knock down, shore up or build on. The installation was part of Phase 3 of the hospital’s PACS (picture archiving and communications system) implementation done with eMed Technologies Corp. (Lexington, Mass.). Phase 1 kicked off with teleradiology; phase 2 set up compression servers and the archival portion, connecting modalities and ensuring that all were DICOM-compliant; Phase 3, or what Schotten calls the “major build out,” equipped all floors with viewing stations and moved in the DR equipment. Currently, the hospital is marrying its radiology information system (RIS) with its McKesson/HBOC (Alpharetta, Ga.) hospital information system (HIS), using a broker from Trilix Information Systems Inc. (Pleasanton, Calif.), a company acquired by eMed in March 2000.

Yuma’s extended plans call for a Web server to be up and running in about a year. Meanwhile, like most other facilities new to DR, Yuma continues to print film, although Schotten indicates printing is already on the decline.

“I would say we saw about a 25 percent reduction in our film utilization budget, and we will in our next year see a reduction in the cost of chemicals since we will be transitioning to dry laser,” he declares. “We planned out to reduce about 25 percent over three years. We already saw 25 percent, we hope to get another 25 percent, and in the next year, the last 25 percent, so we will be at a 25 percent utilization from three years previous.

“Right now you have the major physician community that still wants to see images on film. You have to get total buy-in from physicians to say, ‘Hey, I want you to do this or that,’” he adds. “We do have the option to go on paper, which is much cheaper, and there’s also burning images on a CD-ROM and sending them to the doctor with a reading program on it, but many offices are not up to that technology yet.”

As a facility that ranked service concerns paramount during its DR deliberations, Yuma has not been disappointed with its decision to purchase DR.

“The Swissray service has been outstanding,” Schotten emphasizes. “Since getting through the initial install in December, we had little tweaks that had to be done for the first couple of weeks, and we basically had one day of downtime that I can recall that has been effected and that is just due to receiving a [replacement] part. We are serviced from the southern California area, probably 200 miles away, but apparently we now have somebody who can come from Phoenix.

“I can honestly say that just about every example and claim that was presented to us prior to our purchase has been realized,” he says. “We have only one tiny software issue that we are trying to work out and we have to go back to who’s writing the softwares, both ways, because eMed uses one company to do some of their software fixes and Swissray uses somebody else. So we are getting to the point where we are doing the fine tweaking and finding out that that becomes a little more difficult, a little more challenging. Those processes are long because that becomes an extremely minor customization. It is hard to them to justify putting those many resources on one issue for one facility, but that is what we expect, and I think we will eventually get to that area.”

DR the second time around
The Gulf Coast Veterans Health Care System (Biloxi, Miss.) wishes it could have had as positive an experience with its first DR installation. But rather than adopt a gun-shy attitude about the technology, the VA gave DR a second chance. Now, according to pathologist Paul Watson, M.D., chief of imaging since December 2000, “for anything that can be done from a standing position, it is the unit of choice.”

Last fall, the Gulf Coast VA took delivery and set up of a Hologic Inc. (Bedford, Mass.) Radex system with wall-mounted U-arm. The Radex’s arrival preceded an enterprise-wide PACS installation by a couple of months to ensure that the Hologic unit would mesh with the VA’s own information networks, including its VistA (Veterans Health Information Systems and Technology Architecture) Rad, a radiology information system, and its VistA Imaging, viewing stations that tie into the hospital information system to allow access to a computerized patient record. The system serves the 55-bed Biloxi VA and links it with the hospital’s clinics in Mobile, Ala., and Pensacola and Panama City, Fla. It averages 1,000 studies a month.

“The VA has been subdivided into what they call Veterans Integrated Service Networks (VISNs) and our particular VISN is the largest [of 22] in terms of budgets and patients, and it covers from western Florida to Houston to Oklahoma City and everything in between,” Watson explains. “We are kind of unusual because we are more spread out, and more of our patients are not really central. Most VA facilities are a little more centralized with the hospital and few of them have clinics, but not to the extent that we do.”

When Gulf Coast went scouting for DR, it did not have to dicker about price; the VISN handled that side of the transaction. And productivity gains — while absolutely beneficial during the 10 a.m. to 2 p.m. influx when vans drop off then pick up veterans who live as much as a two-hour ride away — were a consideration, albeit not a pressing one. Watson admits, though, that even he was surprised when a technologist told him she can X-ray 10 ambulatory patients in 20 minutes: “I thought she was going to say 30 minutes, but she said 20. I challenged her, but she insisted.”

But DR is definitely helping Gulf Coast become a filmless operation which offers several pluses: reduced printing costs, fewer orders for repeat exams and the ability to transmit images to its out-of-state clinics.

“We are not printing as many cases,” says Watson. “Since referring physicians can see the images on their PCs, that has eliminated the need for films. For instance, there is a morning surgery conference with the residents [from the surgical residency program with neighboring Keesler Air Force Base] and they used to have a view box and hang all the films. Now they are projecting the images off a PC at the hospital.

“Another advantage in our situation is, because our turnaround time for getting reports on our images is not ideal at the present time, the doctors are at least able to see the images, and then they don’t order another chest [study]. If doctors don’t get a test, be it X-ray or lab, in what they feel is a timely manner, their tendency often is to reorder.”

Image quality, the issue that grounded the VA’s earlier DR installation, is not an issue this time around. Watson indicates that he has heard no negative comments regarding quality, and David Wagner, chief of the Information Resource Management section who was involved in the purchase, notes that, “As far as I know, the radiologists really like reading from it. But the best part about having DR is that they can pull up images from anywhere. We do have outpatient clinics and they can just view those images from down there. We do print film, but we try not to,” he says. “It costs money.”

Thinking DR? Think global
The cost of going digital is always an object. Yet when Clarian Health Partners (Indianapolis, Ind.) began investing $20 million in a PACS that would serve its Methodist, Indiana University Hospital (IU) and Riley Hospital for Children facilities, nothing but DR made sense.

“We do a lot of research at the university and it was kind of a decision based on research,” recalls Stanley R. Metzger, administrative director, Clarian Radiology. “We certainly liked the images it produced; we thought those were excellent. And with the PACS, it was digital so that gives us the interface straight in, and we also are putting in a new RIS, so between the combination it was, ‘OK, we are going to bite the bullet and pay the higher price.’”

Metzger declines to discuss price, but says Clarian put its money on an Eastman Kodak Co. (Rochester, N.Y.) Health Imaging division DirectView 5000 system, which Kodak markets for Hologic. The 5000, which is used primarily for chest X-rays, was installed last October at IU, a tertiary care center licensed for 350 beds, but generally operates at 250 to 290-bed capacity.

Like Yuma Regional, IU chose its DR vendor based on service considerations. And the fact that Kodak had proved it could deliver good service on other equipment it had installed at the hospital helped cinch the deal.

Increasing throughput would have been more of an issue had the unit gone to Methodist, where Metzger pointed out that the National Football League, three days a year, pumps an additional 1,500 procedures into the regular workload, performing combine physicals in preparation for the upcoming season.

“I think the DR is a smoother system — no doubt about that,” he asserts. “But service and support is one of our biggest considerations. I always tell people I can have the absolute best machine in the world, it can run circles around everything else, but if I can’t keep the thing running — so what?

“When I say support, it is a pretty broad-brush stroke,” he clarifies. “I look at training. I look at future software enhancements, improvements in the system, service, all those things.”

Metzger remarks that IU radiologists are impressed with the DirectView 5000, so much so that they swear that DR is providing them with more information than was possible with film-screen images. Technologists weathered the change well and are recording few retakes.

“DR takes what you have learned and makes it better, and if you do err a little bit with the technique, it certainly gives you the capability of correcting your error without re-exposing the patient,” he states. “That is where I see the advantages. We have essentially zero retakes. You are not exposing the patient unnecessarily and again, that increases your productivity.”

Productivity also gets a boost when film is no longer part of the picture, and Metzger anticipates that IU will stop printing film by the end of the calendar year. Because IU is not yet hooked up to PACS and the RIS is brand-new — the first quarter of 2002 is the target date for all to be up and running — images are available only on film and cannot be beamed to referring physicians. “That is not necessarily the way I would suggest most people use this,” he advises.

“I would not buy DR unless your future plans were to go filmless; I don’t think it is cost-effective. If you are going to continue to use film, even if it is dropping out on dry view laser, I still think it is an expensive way to go. You need to go filmless. That is the application of DR.”

Although IU selected a detector that is basically a dedicated chest unit, Metzger suggests that a small hospital mulling DR might be better off with a more universal system capable of X-raying lumbar spines, extremities and other body segments. And he reiterates his belief that DR works best when a facility sets its sights on going filmless.

“But you don’t get all your savings just from the fact that you are going filmless. That is the bulk of it,” he concedes, “but it is an overall productivity increase from the standpoint that now you have the capability of interfacing into your RIS. It’s kind of a global-type thing to me.” end.gif (810 bytes)