We still print on average between 10% and 15% of our case mix,” says James H. Thrall, MD. “When we started into the PACS era, we imagined a filmless department. The words were right, but the order was wrong. It’s a less-film department.”

Thrall is professor of radiology at Harvard Medical School and chairman of the radiology department at Massachusetts General Hospital (MGH), Boston. When MGH put in its picture archiving and communications system (PACS) in 1995-96, Thrall says, the focus on reducing film usage was intense. And, to a large degree, it has been successful.

“We were spending about $4 million per year on film and the handling of film,” he says, “about $2 million on the film and another $2 million on the handling. Today, we are spending a total of about $500,000. But if we take all the imaging growth into account and the multislice proliferation, I estimate we would be spending between $7 and $8 million on film and film handling. We have spent $5 to $6 million putting in PACS, so we’re ahead of the game already.”

While these figures sound good, Thrall is the first to admit that they may need interpreting. “What is a PACS?” he asks, noting that some hospitals include buying PCs for clinicians and installing CR and DR image-capturing capabilities on modalitiesto convert them to digital imagery capable of PACS distributionas part of the overall cost of the PACS. “If they buy PCs and chalk that up to PACS, that will make the return on investment (ROI) on the PACS look worse. No two hospitals approach the ROI in the same way. It just so happened at MGH that the year before we installed our PACS, the hospital had purchased PC desktop workstations for every doctor that practiced here as part of an EMR (electronic medical record) effort. That network was already in place. We didn’t insist on charging that as a component of PACS,” Thrall says.

At Children’s Hospital Boston, which is also affiliated with Harvard, S. Ted Treves, MD, has helped deploy a PACS system that began with a mini-PACS 15 years ago and is just now being converted to a full-blown institutional PACS. Treves is vice chairman of the radiology department information technology team. He is also chief of the division of nuclear medicine, where the mini-PACS was deployed years ago.

Treves says that among the many justifications for PACS, film savings is somewhere down from the top. “There is no way film savings will justify PACS,” he says. “If you focus on film savings, you are missing the boat. The PACS is an important part of the infrastructure. There are huge operational savings. But someone could develop a career just trying to quantify all of that.

“We have a project costing several tens of millions of dollars over 5 years,” he adds. “You never stop building PACS. Overall, you may break even, but you can’t ever prove that. It’s a moving target.”

At the Veterans Affairs Medical Center in Baltimore, Eliot Siegel, MD, supervises imaging at the main VA hospital and several smaller hospitals and clinics that make up the Maryland VA system. He is not only the VA’s chief of imaging, he is vice chairman of radiology at the University of Maryland Medical School.

Siegel agrees with others who say that purely reducing film usage is a lesser motivation for installing PACS. “Reducing film wasn’t a goal per se. The savings with film have been significant but third or fourth on the list behind saving space, saving personnel cost, and improving efficiency.”

The Baltimore VA put in its PACS in 1993. It was able to join forces with the Department of Defense (DOD), which was searching for a PACS big enough to handle its military hospitals. The Baltimore VA was able to use the same vendor as the DOD. Baltimore wanted PACS badly because it was opening a new hospital that it planned to be state-of-the-art. Space was at a premium because while the hospital was new, the site was old and crowded. There was no room for a lot of darkrooms and a film library, Siegel says.

Since 1993, the Baltimore VA has cut its film use by 98%, Siegel says, a remarkable percentage when compared with public hospitals. “We print zero film for everything,” he says. “We haven’t had film since pretty soon after we opened. Our surgeons have been reading off monitors for 10 years.”

Siegel agrees that the VA is a special case. Because it has an overwhelmingly male patient base, it does very little mammography. For the tiny volume it does do, it still prints film. It also prints film for its patients who go to other hospitals or who may be involved in compensation disputes where outside experts are brought in. “We have a film printer, but inside the facility there is no film,” Siegel says. Even the mammograms, which the radiologists read on film, are run through a digitizer and put on the PACS for the referring physicians to look at, Siegel says. Because the VA does not have to deal with a civilian population of patients and their doctors, it can dictate imaging practices more easily than others can. “Every institution has its own strategies for film reduction,” Siegel says. “All strategies don’t work the same.”

Paperless and filmless

To get rid of film, the Baltimore VA met with clinicians and began to prepare them to read off monitors. Siegel says the PACS team was prepared for more resistance than it got. “We were surprised that the orthopedic surgeons and the neurosurgeons weren’t more resistant. But they seemed pretty enthusiastic.” Within a few months the Baltimore VA was filmless. At the same time, it was integrating its RIS (radiology information system) and its HIS (hospital information system) with the PACS in a push to go paperless as well as filmless. It was not easy, Siegel says, but it paid off. “The secret for us is being paperless, which has eliminated a lot of steps in the workflow. Those who don’t see a cost saving with PACS haven’t rearranged the workflow. They are emulating a film environment with PACS.”

With chest x-rays, for instance, Siegel says, the Baltimore VA originally isolated and documented 59 manual steps in a film environment. Since PACS, it has eliminated all of those steps but nine. “In CT we reduced the manual steps for technicians from 11 steps to five steps. It’s amazing how much faster they are with less fatigue. Our technologist productivity is far in excess of the national standards of the American Healthcare Radiology Administrators.”

Another part of the Baltimore VA’s strategy has been to carefully limit who is allowed to use film. “The doctors have to request it. Only a handful have the privilege to print film. Having the PACS lets us decide who gets film. We encourage them to use CDs. Our film cost might be $1.30 per sheet. Large studies can be burned on CDs, and CDs cost 20 cents.”

Even surgeons using templates for surgical measurements have learned to do them using electronic images, Siegel says. “An orthopedist sees that he can zoom the image on the monitor so the marker is the same as the actual space on the screen. They put the orthopedic template right on the screen. They have learned tricks like that.”

Siegel says the Baltimore VA has been able to document its savings with PACS overalla surprising 25% reduction in the “unit cost per [imaging] study over what it would have been with film.” Siegel says the Baltimore VA is saving over $1 million per year with PACS. “We originally thought PACS would be more expensive [than film], but we are 40% to 50% more productive.”

An uphill climb

While some hospitals have succeeded in taking radiology departments filmless with PACS, most hospitals have been extremely cautious about disrupting the practice patterns of those clinicians who continue to demand film. In fact, which doctors get film may not be up to the radiology department at all.

At the Cleveland Clinic Foundation (CCF) in Ohio, the situation is almost the opposite of the well-controlled VA environment. CCF not only has its main campus in Cleveland, it has a string of hospitals and family centers in the Midwest and two more hospitals plus clinics in Naples and Ft Lauderdale (Weston), Fla. It began building and deploying a PACS in 1994.

According to Louis Lannum, Cleveland Clinic’s administrator for radiology informatics, in 2002 CCF did about 1.3 million imaging examinations across the enterprise. “Of those, about 800,000 were digital, and of the remaining 500,000, about 300,000 can be converted through CR or DR. The remaining 200,000 are mammography where it has not been feasible to put CR/DR.”

Lannum says CCF has made great strides in taking its radiology departments filmless, connecting the various sites so that PACS images can flow between them. As an enterprise, however, CCF has reduced its filming of images by only about 25%, and at the main campus virtually everything is still put on film. The reason for this, says Lannum, is twofold: many clinicians still prefer film. CCF administrators are loath to disrupt practice patterns by withholding film. Second, even if administrators wanted to withhold film, they could not because, according to Lannum, many clinicians still do not have desktop PCs capable of adequately displaying images. Additionally, servers robust enough to distribute the images still are not in place. “More than 1,000 PCs still need an upgrade,” Lannum says. He estimates that only about half the clinicians at CCF’s main campus could get electronic images if they wanted them. “User preferences and access to images have been major factors in our continuing to print film.” Additionally, CCF is still integrating its RIS and HIS to the PACS at the main site.

To help it solve the complexities of its distribution, CCF is developing its Naples, Fla, hospital as a model site. “The only film they produce is for the OR, and they have integrated the HIS and the RIS with their PACS. That is now an initiative at the main Cleveland campus,” says Lannum. “We will use Naples as a technical guide for what we want to do at our other facilities, plus an operational guide for where we want to go. When I came here in 1999, I had three servers in my archive. I’ve got 10 in my archive today. That’s a reflection of how fast we are growing digitally. But we aren’t completely there yet. We have found out it is very much of an uphill climb.”

GET Information Technology involved

At Children’s Hospital Boston, the nuclear medicine department stopped printing film long ago. Now it uses paper printouts for those clinicians who demand them, says Treves. The rest of the institution, which conducts about 160,000 imaging studies annually, is now deploying PACS with the intent of matching the success of nuclear medicine, Treves adds.

In deploying PACS, Treves says it is vital that information technologists within radiologyTreves heads the 12-member radiology IT teamwork closely with the hospital IT team and the vendors to achieve maximum PACS functionality and cut film usage. “The hospital IT people are very important,” he says. “A hospital may be very successful inside the radiology department, but if the hospital IT is not on board, they can’t communicate the PACS information to the rest of the enterprise. In an institution like ours, that’s shortsighted. If the radiology IT and the institution IT aren’t talking, that’s a big mistake.”

Treves says it is also important to engage clinicians early in the deployment of PACS to forestall continued dependence on film. (see sidebar, page 48) “We meet with those physician groups and try to understand their workflows and their imaging needs so   they can remain satisfied and at the same time adapt to the electronic world. We engage them early on. For orthopedics, which is 50% of our imaging, we are meeting with them weekly to examine what happens on their side of things. If we just cut off their film, we will impinge very negatively on their practice, and we cannot do that. So it is more than radiology. You have to go to the client. We know that if we don’t involve them, we will get resistance.”

To display PACS images, the facility is deploying three levels of workstations, Treves says. The top tier employs diagnostic workstations on which primary reads can be done; an intermediate level uses conventional PCs with high-end monitors; and the bottom rung involves hospital-issued ordinary PCs.

The hospital does not intend to digitize its film archive, a process Treves calls “too cumbersome and too expensive.” Already, he says, the radiology reading rooms have been set up to accommodate light boxes next to workstation monitors. “The monitors are large and bright. Our reading rooms are not dark any more. We can go from the digital image to the film image without adjusting our eyes. You can co-exist with a light box.” This is an important step when images of child patients must be kept for 51 years, he adds.

Being first

Being the first institution in a market area to install PACS can have its drawbacks, particularly if one aim of the PACS deployment is to cut film usage. That is the opinion of John Contrael, MPA, RT, radiology director for Rex Healthcare in Raleigh, NC. At its main hospital, which is licensed for about 400 beds, and at an outlying hospital and at outpatient centers in nearby communities, Rex does about 175,000 examinations per year. Rex has deployed the first PACS in its area. It also has the first PET scanner in its county.

“Since we have a full-blown PACS and the others don’t, the expectation among referring physicians still seems to be film. It has taken us longer to wean them than we thought it would. The physicians fresh out of college love the PACS,” Contrael says.

Rex installed its PACS in 1999. It began by converting all outpatient imaging and all emergency department imaging to the PACS and expanded the conversion from there. “The first year or two the goal was to reduce film and free up people to help grow the department,” Contrael says. “We took a phased approach, captured a hill, gained confidence, captured another hill. We did the diagnostic section first, then CT, then MR, and then ultrasound at 6-month intervals.”

The deployment strategy devised at Rex has been remarkably successful. The system prints virtually no film within radiology. As many referring physicians as possible have been given web-based access to the PACS. Others are encouraged to use CDs instead of film.

“Last year we had 7,400 requests for film out of the 175,000 images. We would like that to be zero,” says Larissa Green, RT(R)(MR), Rex’s radiology operations manager. “When we started in 1999, I had one file room employee for every 8,000 examinations. Now I have one for every 35,000 examinations. We went from 16.5 FTEs to five, while increasing volume. We were paying $343,000 in salary alone; now we’re paying $135,000,” Green adds.

Contrael says another benefit of the PACS has been acquiring space that would have been required for film handling. “Other departments are calling me saying, Can I use that space you don’t need?’ We’re using it now to store computers.”

Rex has even devised a home-built, manual-entry system to try to track all the film that it reprints from PACS. “A patient may request film or a physician’s office; a second opinion may require the same set,” says Trilby Bryant, RT(R), Rex’s radiology systems support specialist. “A PACS really offers an endless supply of images for reprinting. It’s very important to track that.”


Another motive for moving to less film through PACS, in addition to the cost savings, is to enhance the integrity of the radiology department, says MGH’s James Thrall.

“When we first turned on our RIS in 1988 (long before the PACS was deployed in the mid 90s), we discovered that fully 10% of our film was never being interpreted by radiologists. The culture of the institution did not respect the integrity of the radiology film library, or the integrity of checking out and returning film in a timely fashion. The studies were being taken from the department before they had been interpreted,” Thrall says. “When we moved to the RIS, that reduced unread film to 3%, and we have since reduced it to zero.”

MGH deployed its PACS by modality, starting first with CT and MRI. “They are image rich and low resolution and ideally suited for electronic review to take advantage of workstation tools. They are also, from the standpoint of film, very high cost.”

Thrall says that in the early days of PACS cutting off film to practitioners was “a tricky political issue.” But he says that has changed. “The general computer literacy among physicians has skyrocketed, and we have a whole generation of young doctors in practice today who grew up in the computer era.”

The secret of really using less film, he says, lies in going electronic enterprisewide. “I see the biggest successes in those cases where the institution is committed to the EMR and to having a high-level computer functioning on every doctor’s desktop.”

It pays off in more than just film reduction. “We have seen a 30% increase in the number of RVUs [relative value units, a measure of work efficiency] for our staff radiologists. This has benefited faculty salaries, and it adds to the quality of work life.”

As for any draconian crackdown on clinicians over film usage, Thralls says that is a mistake now. “If we had it to do over again, we would be even more permissive about printing film, because we know it’s just a matter of time before people become converted to the benefit of electronic images. The other day, the chief of cardiac surgery had the most interesting comment when we were briefing in the cardiac ICU on how to use the workstation. He said, I’m sure we’re going to hate this for some period of time, and after that we’ll be lost without it.”

George Wiley is a contributing writer for Decisions in Axis Imaging News.