Due to the technical complexities of the endeavor and the corresponding need for changes in human behavior relating to work flow and work habits, radiology departments and imaging centers customarily elect to convert from film-based to filmless operation in stages, rather than in a single grand leap. It involves too much money, too much disruption, and too much resistance to do it any other way.

Thus, the journey to a fully electronic environment typically begins with soft-copy reading for CT/MRI/US, and the introduction of computed radiography (CR) in one or two sections of the department or center to acquaint just a few radiologists and staff at a time with soft copy. Later, the basic hardware and software elements that constitute a picture archiving and communications system (PACS) are installed and made operational so that electronic storage and online distribution of the digital images can commence. Gradually, the enterprise connects one modality after another to the PACS. Film use does not immediately recede, however; producing and keeping hard copy as a backup leaves administrators and radiologists feeling more comfortable than they might if they were to rely exclusively on PACS and soft copy.

That is just the way that Presbyterian Hospital of Greenville (PHG), Tex, planned its transformation to filmless operation, until radiology decision makers determined that the effort would be less problem-ridden if conversion took place in an almost overnight fashion. Kyle Moore, RT, is CT-MR coordinator and PACS administrator in the hospital’s department of diagnostic imaging. “We weren’t very far along in our phasing in of filmless operation before we realized that running a dual environment of soft copy and hard copy was too much of a headache and a waste of resources, not to mention a huge source of confusion,” he says “We decided that we would just discontinue film, do the full PACS implementation, and go straight to soft copy only. Film was an obstacle, so we moved it out of our way with the radiologists leading the effort.”

Taking this bold course was not easy, Moore confesses. “There were plenty of rough spots,” he says. “Learning to work with soft copy was challenging enough for most everyone, but it was especially when it was being thrust on them rather than their being eased into it. For example, it was helpful to have some computer experience; without it the radiologist would take longer to read each image because the steps to manipulate the displayed image weren’t intuitive and took some getting used to.” He continues, “We also were asking all of our staff to alter their familiar ways of doing things to a large degree and in a real hurry. Our people gritted their teeth, though, and put themselves in the frame of mind of wanting this to be a successful changeover. No one ever gave in to the impulse to throw in the towel. Team spirit and the desire to make something good happen were both really strong.”



Licensed for 148 beds, PHG is the main facility in the Hunt Memorial Hospital District. The district’s other care centers include a 30-bed hospital in the nearby town of Commerce and an outpatient clinic in Quinlan. Most patients using PHG are from Hunt County, population 76,596, an 882.1-sq-mi area built on cotton farming and railroads, but now also home to a variety of industries, including high-tech businesses.

In the past few years, PHG has experienced respectable growth in both inpatient admissions and the use of outpatient services. Hospital officials say that this is the result of improvements made to the physical plant and to departmental offerings, radiology’s among them.

From left, Kyle Moore, RT, Nancy Rodriguez, PACS administrator, Pat Jonz, RT, and Lawrence W. Kalet, MD, PhD, Presbyterian Hospital, Greenville, SC.

“Previously, patients looking for top-flight care preferred to make the 50-mile drive into Dallas, where all the large hospitals and major-league medical providers are located,” Pat Jonz, ARRT, assistant director of diagnostic imaging, reports. “Today, patients? more often prefer to stay here in Greenville for the services they need because we’ve put ourselves on par with or above with competition in Dallas. Diagnostic imaging is a perfect illustration of what I mean. The hospital has made major investments in state-of-the-art imaging technologies and, as a result, patients are able to have the kind of diagnostic workups without leaving their home town.”

Prior to the decision to improve services, the outpatient imaging department’s equipment complement listed one mammography machine, one aging ultrasound unit, one R/F unit, and one badly outdated CT scanner, Jonz notes. The impetus for the department to modernize and broaden these capabilities was the announcement by district officials that they had approved PHG’s plans to construct a two-story medical office complex next to the main building, which would also house a new outpatient imaging facility with inhouse MRI. “The purpose of the medical office space was to provide a convenient central location in which all family practice physicians in the area could base themselves,” Jonz explains. “These physicians had been spread among several different remote sites, some with analog x-ray equipment; upon relocation to the medical office building, these physicians would begin looking to the diagnostic imaging department to perform their radiology work for them. We knew that we weren’t going to be able to serve these physicians properly with just the equipment we had on hand. The hospital was also working toward meeting all of the diagnostic needs of our outpatients including laboratory and cardiopulmonary access in the same area.”

Construction of the new building began in 1994 and was completed in 1996. The outpatient diagnostic imaging department, housed until then in an offsite facility, took up residence on the new building’s second floor. The inpatient imaging department remained on the second floor of the main building with future plans to enlarge and upgrade all of the equipment. A fiber-optic backbone had been incorporated into its construction; this gave the imaging department a foundation upon which to establish its filmless environment between the inpatient and outpatient departments and throughout the hospital. “Actually, we had begun inching our way toward filmlessness while we were still in the construction phase,” Jonz clarifies. “In 1996, we acquired a miniPACS consisting of a small jukebox, an archive sever/network gateway, and one reading station. The modalities linked to it were MRI, CT, nuclear medicine, and ultrasound. We felt that this was a good way to find out what filmless operation might someday be like in our enterprise, but the technology was not mature enough to do what we wanted. It was slow and cumbersome. The radiologists gave it a try, but then gave up on it because of those shortcomings.”

Department leaders, however, were unwilling to brand this dabbling in PACS a failure. “We didn’t give up on the idea of one day creating a filmless environment,” Jonz says. “Filmless operation was the future, and we knew that. We just had to wait for the time to be right. That meant the technology had to advance to a point at which it would meet our expectations.”


The right time arrived for Presbyterian Hospital in 1996, and not solely because the new, network-ready building was ready for the department to move into it. That year, concern for complying with local environmental regulations had reached a fresh peak. “We have very stringent clean-water rules here in Greenville,” Jonz says. “We felt it would be difficult (perhaps, even impossible) to be in compliance with those rules if we continued generating film, especially given the increases in volume we were anticipating. More volume would mean having to acquire more chemical processors on top of the seven we already had in operation in the county. More processors would mean more chemical waste products that would have to be treated prior to discharge into the sewer system.”

As it moved into the new building, the department began to push, in earnest, for the filmless environment always known to be just around the corner. Digital modalities were deployed and laser imagers were acquired to translate computed images from those modalities onto film and the small archive.

“The next step was to replace the miniPACS? that we had experimented with 2 years earlier,” Jonz says. “The only thing holding us back was the need to convince our administration, radiologists, and imaging support staff to go along with the idea of having a full PACS.”

For this, the services of a champion were needed. Rising to the occasion was radiologist Lawrence Kaler, MD, PhD, who is now medical director of diagnostic imaging. “This was the perfect time to do this because HMHD was beginning another construction project to enlarge the emergency and surgery departments,” Jonz says. “Our administration and board of directors were fully supportive of a filmless environment. Dr Kaler’s activism for PACS was crucial to the success of our efforts. He proved very persuasive in rallying the troops. Thanks to Dr Kaler, we received the buy-in that the effort required.” The imaging department then proceeded to acquire a full PACS, including computed radiography, which was installed in late 1998. The technology was far superior to that of the earlier system, and radiologists and administrators alike seemed delighted by it.

“One of the things we liked best about having this PACS was the notion that, once we got around to converting to full filmlessness, we weren’t going to have the problem of lost film,” Jonz says. “As a level-III trauma center, we find it a fairly routine event for to take patients out of here by helicopter and fly them to Dallas. Before PACS, all the images taken during a trauma patient’s stay had to be gathered up and placed in the helicopter with that patient. If our film duplicator was down, that meant that the images going onto that helicopter would be the originals (and the only ones in existence). The risk of losing those in another hospital was always present and always substantial. Should loss occur, there would be no way to recover the images.” Jonz continues, “Consequently, lost film always represented a crisis. You couldn’t bill for images taken if you lost them, because you couldn’t prove that they ever existed. Worse, you made yourself vulnerable, in lawsuits, because lost film meant that you had no evidence to present on your behalf.”


The additions of the digital modalities, CR, and PACS each delivered to the department a certain degree of new efficiency. To maximize those gains in efficiency, however, the department had to reorganize the way that work was performed. One such revamping came in the form of assigning clerical staff the task of printing the occasional hard-copy image. “Relieving our technologists of the burden of performing this particular chore has freed them to focus on other tasks where their time and talents can be put to more productive use, such as interacting with patients and assisting other technologists with hard-to-handle patients,” Jonz says. “Before this could happen, though, the clerical staff first had to be taught how to use the PACS technology to retrieve, format, and print images, which is far more complex than pulling a folder.”

Nancy Rodriguez, the department’s supervisor of diagnostic imaging and PACS, confirms that statement, adding that the instruction process consumed much time and effort. “During the training of the clerical staff, some of the technologists had to be called upon to lend their expertise,” Rodriguez says. “For example, we had a CT technologist assigned to review each of the CT images printed by the clerical staff before forwarding them to referring physicians. The technologist’s responsibility was to make sure that the images were printed correctly. If problems were found, the technologist would call attention to the mistakes so that the clerical staff member involved could receive further instruction and be able to avoid making those mistakes in the future. The technologist, of course, had better things to do, but this was a worthwhile activity. Not only did the clerical staff members learn what they needed to learn, but it also served to increase the comfort level of the referring physician. This process assured him or her that the films that were received were formatted and sized correctly, even though nontechnologists were involved in their production.”

Nevertheless, it was a risky gambit, considering that the turnover of office workers tends to be very high, even in the best and most nurturing of institutions. The fear was that no sooner would a clerk be trained than he would give his 2 weeks’ notice of intent to leave. Presbyterian Hospital was fortunate, though; its clerical team was reasonably stable, with few members leaving. “When we did have departures, there were always enough long-timers remaining to supply continuity and to help train the newly hired,” Rodriguez says. “In that way, our initial investment in clerical staff training was never wasted.”


Presbyterian Hospital of Greenville acquired its PACS from Agfa, the international leader in this and other imaging technologies. The system was, at first, configured to run version 2.x of the PACS software that Agfa had developed. Before upgrading to version 3.5, radiology leaders wanted to know whether, in the future, they should continue relying on Agfa’s PACS solution or that of some other vendor. “We decided to look around at what else was on the market,” Jonz says, “because we wanted to make sure that we were aligned with a company that would continue to meet our needs in the years ahead. There had been rapid advancement in the technology in the prior year or two, and we wondered if a different vendor could provide something superior the next time we decided to upgrade. We wondered if the direction we had taken up to this juncture was one that we should keep following.”

Jonz continues, “After an exhaustive exploration of the offerings in the market, we made the determination that? no other vendor was as far forward as Agfa with a complete PACS solution. Sure, there were vendors that had attractive individual pieces, but we were very reluctant to take the approach of cherry-picking the best PACS components of vendor A and then trying to match those with the best of vendors B, C, and D. In addition to anticipating serious problems integrating the various vendors’ components into one cohesive package, we imagined that there would be unbearably counterproductive finger-pointing any time that things didn’t work to our satisfaction. Needless to say, we all came to the conclusion that the smartest move was to remain with our current and only PACS vendor.”

In November 2000, the department upgraded its PACS again, this time to Agfa’s software version 4.0. Unlike the previous upgrades, version 4.0 required deployment of new hardware . “We went from a Unix?-based platform to a Windows NT?-based platform,” Rodriguez says. “It enabled us to distribute images more quickly, to more users, and at higher resolutions, but there was a problem. We had become supremely familiar with the intricacies of our version 3.5 system. If a user encountered difficulties with the version 3.5 system, we could resolve the problem in minutes; that’s how intimate we were with its workings. In going to an entirely new platform with all new software features, we lost that familiarity. Until we regained it, we were operating at a real disadvantage. Kyle and I are pleased with the benefits of Release 4 because the service tools enable inhouse and remote system management and the cacheless environment increases departmental efficiency while decreasing network traffic.”

No less daunting was the effort to link the various makes of modalities to the new hardware and software. “The archive servers and network gateways were all still Unix, while the outlying components-the diagnostic and clinical review stations-became Windows NT,” Moore says. “Host connectivity was a big challenge. All the modalities were compliant with the Digital Imaging and Communications in Medicine (DICOM) standard, their vendors said, but we found out that one vendor’s DICOM compliance meant one thing, while another’s meant something else. This was because DICOM compliance was such a broad statement, with much room for variance. This made it hard for us to deliver, to the radiologists, on-screen images containing complete demographic information, that were in the correct window width and level, and in the proper hanging protocol.” Moore adds, “This is important because, when the radiologists click on that folder to be viewed, they want it to come up and look just the way it would if it were film on a view box.” With Agfa’s assistance, these glitches were corrected. Satisfied with the running of the system, the department turned an eye to the future and other possible enhancements.

“Our next challenge is going to be long-term storage,” Jonz says. “To be specific, we need to decide how we will accomplish the archiving of our oldest images. We know that successfully meeting this challenge depends on how well informed we are about the options that exist, the pros and cons of each, and their costs. I can say only that we’re in a good position to become informed to that extent, thanks to the relationships we have with our vendor. Agfa has been doing an excellent job of keeping us aware of the newest developments.” Jonz concludes, “As things now stand, we’re very pleased with the outcome of our efforts to become filmless. Our volume of examinations has increased, but we have not had to hire additional technologists. Our radiologists feel they are much more efficient and shudder at the thought of going back to hard copy film and viewboxes. The only occasions we have for producing film nowadays are mammography and when a physician outside our hospital system will be seeing one of our patients. Getting to the filmless state was a somewhat bumpy ride, but a trip well worth taking.”

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