What do Disney, Kelloggs Corn Flakes and computed radiography have in common? (For purposes of this story, there truly is a link.)
Florida Hospital Celebration Health, a 60-bed hospital built from the ground up in the Disney-designed town of Celebration, Fla., owes its philosophical roots in patient care to the Seventh-day Adventists at whose medical retreat in Battle Creek, Mich., Dr. John Harvey Kellogg trained and eventually developed corn flakes as an alternative, healthful breakfast food.
Computed radiography (CR) hitched itself to that hallowed lineup when it was viewed as fitting into both Disneys and the Adventists views on the personal attention, respect and treatment patients deserve. So when Florida Hospital Celebration Health swung open its doors on Jan. 5, 1998, as the the hospital of the future, according to Sally Grady, director of imaging for Celebration Health and Florida Hospital Kissimmee, that future predictably included imaging with CR.
In spite of all the fanfare surrounding flat panel and charged-couple device-based digital radiography (DR), hundreds of healthcare providers across the country still make CR their DR of choice.
These facilities are not settling for CR because they could not wrangle a larger, more expensive DR system out of the CFO. They are not putting up with CR until the REAL digital X-ray system comes along. They do not regard CR the way some families contemplate distance cousins to be tolerated, at best, but never quite accepted nor embraced.
Take, for example, the aforementioned Florida Hospital Celebration Health.
Owned and operated by the nonprofit Adventist Health System (Winter Park, Fla.), the existence of Celebration Health honors the natural health principles held by the founders of the Seventh-day Adventist Church fresh air and sunshine, exercise, nutrition, rest, relaxation, avoiding tobacco and alcohol use, to name a few and espoused at a time when doctors used leeches to bleed patients, prescribed smoking to cure coughs, and regularly dispensed narcotics and alcoholic elixirs to treat a myriad of complaints.
In keeping with that Adventist ideology, Celebration Health presents itself as more than just a hospital: The lobby exudes the ambiance of a Mediterranean-style hotel and opens to a four-story atrium. A concierge greets patients, known as guests. The building incorporates a 60,000-square-foot fitness center outfitted with an Olympic-size pool, full-court gymnasium and exercise equipment. The clinical core includes an inpatient section with 60 beds, an imaging department, a surgical unit, orthopedics and more. As Grady puts it, We have everything a hospital would have.
But Celebration Health also is noteworthy for what it lacks.
It has no file room. There are no X-ray jackets, except for mammography, but even that could vanish soon: The hospital went live with digital mammography in late June. We made the promise to ourselves that when we opened we would not shoot film, states Grady.
Celebration chose Agfa Corp. (Ridgefield Park, N.J.) as its partner in its filmless venture for several reasons, one of which was Agfas experience with, and approach to, CR.
In looking at their product and the way they were developing their product, we saw it as something that would take us into the future and could also serve a system that, at that point, had only six facilities, Grady begins. (A seventh has since been added.) We have been ever-growing, ever-expanding and we wanted a system that could accommodate this kind of volume. We do close to 750,000 exams a year system-wide, and you need a company that is going to have a pretty good backbone. On CR, if we stay on the path were on right now, it will be about 25,000 exams a year. We do all exams on CR that can be done on CR.
Currently, Celebration has one ADC Compact, a high-volume system with 10-cassette capacity, and one ADC70, a larger and now older model, although the facility opened with ADC70s, Agfas newest at the time. Gradys strategy is to keep Celebration stocked with new equipment and to transfer older models out to other locations within the seven-hospital system.
I have already transferred two ADC70s to our main campus, and I have a new ADC Compact on order, so I will end up with two ADC Compacts [at Celebration], she explains. Our main campus, which is our largest facility, will end up with three ADC70s. I also have an ADC Solo on order for our surgery use. Celebration was designed to start off with new technology not just
to start off that way, but to stay that way.
But Celebration also selected Agfa because its CR product line fit with the
hospitals own philosophy of patient care.
High-tech and high-touch
One of my goals with CR was to put the tech back in the room with the patient and get away from, Ill be back in 10 minutes after I develop your X-rays, Grady says. When I first put in their older equipment three-and-a-half years ago, they had what they called preview monitors which you physically set on top of the ADC70s so the tech could come out of the room and view images. I purchased extra preview monitors and I stuck them inside the rooms so that the techs could walk out the door for two or three seconds, dump all their cassettes, walk right back in with the patient and watch the images come up while they talk to the patient.
We try to have a new level of customer service here, she notes. We want to be very high-tech, but we also dont want to lose sight of the high-touch aspect of it. And CR plays into that.
As a show site for Agfa, Celebration has ample opportunity to work with the company on developing technologies. Grady conducts clinical tests for the manufacturer, and the hospitals association with Agfa gives Grady the opportunity to catch a glimpse of new products and services and possibly purchase them sooner than would be available to the market at large.
Obviously, its in Agfas best interest that I remain as state-of-the-art as possible, she says, but I still have to negotiate pricing just like everybody else does. If something is coming out, I may get one of the first few. Sometimes thats good, sometimes thats bad. Sometimes you dont want to be first, she chuckles, adding that, in those cases, its the early bird who gets the bugs out.
As part of maintaining its state-of-the-art status, Celebration also is helping coordinate an Internet training program with Agfa. The Florida Hospital College of Health Sciences, aligned with Celebration Health, has formed a company that offers education via the Internet.
We went to Agfa and we said, We think one of the weaknesses with CR with every CR vendor is training, comments Grady. You come in and train my first staff, but if I have a new staff coming in or a staff thats changing, they learn only what the tech knows. We need a formal training program. So our college is working with Agfa and also with GE [Medical Systems of Waukesha, Wis.] to develop CR and PACS [picture archiving and communications systems] training programs that can be taken over the Internet. We hope to be able to offer some internships here as well.
The entire imaging center for Celebration was designed and built to be DR. Its just that at that point in time, DR was nowhere near ready. Its still a ways from being ready, she declares. I think where the CR product is going will make DR a much less necessary player probably two to three years from now. I think CR is going to get to the point where it is going to be so user-friendly and it is going to be built into your rooms, that people will tend not to focus so much on DR.
Grady points out that all facilities in the Florida Hospital system are expected to convert to CR over time; in fact, she hopes to take Kissimmee filmless by the end of the year. A productivity study she conducted last year revealed that technologists using CR at Celebration performed 25 percent more exams than their counterparts using film-screen at Kissimmee.
Our path is with Agfa all the way, she insists. We dont intend to change.
Kodak: CR and more
Grady wont waver in her commitment to Agfa CR. And Jan Geuy (left) cant say enough good things about her hospitals Eastman Kodak Co. (Rochester, N.Y.) CR installation.
Geuy, director of imaging for Marion (Ohio) General Hospital and the newly established Marion (Ohio) Area Health Center, says choosing Kodak was easy. Yes, Kodak offered Marion the CR it wanted, but more importantly, the company demonstrated a product line that could speed Marion to its ultimate goal a full-blown PACS installation, including a Web product for referring physicians.
When we made our site visits, we went to [vendors] who said they had PACS but when we got there, they really didnt, she recalls. They had CR, but they were still printing film left and right, and our goal was to be 90 percent filmless, leaving 10 percent for mammography. We felt that Kodak would be able to match what our needs were: multicampus and integration. We were able to make site visits and see that happening with other Kodak products.
Marion purchased three Kodak DirectView CR 800 systems complete with storage phosphor reader, QA workstation, patient/cassette/exam identifier and image processor for the hospital. It bought an additional three for the Health Center. The hospital also took delivery of a DirectView Remote Operations Panel (ROP), which allows some routine CR functions to be performed in the presence of the patient. According to plan, the hospital began inpatient imaging with CR in February 2000. The Health Center, which eventually will be responsible for all outpatient imaging, followed in March.
On the hospital side, Marion installed monitors in the emergency room, the intensive care unit (ICU) and at all the nursing stations, so that doctors can easily view the CR images via the newly installed Kodak PACS. High-volume users on the outpatient side have monitors in their offices. Others can access images on a monitor bank in the hospitals radiology area. Of the 120,000 studies added to the PACS yearly, 60,000 are CR.
One of the nice parts of the Kodak CR is that, as I ask staff to go from one institution to the other, the CRs are the same, Geuy remarks. They dont have to learn a whole new system. And when we transfer staff back and forth it becomes a real continuity issue. With the CRs being the same, they can walk in and start to be productive quicker because they dont have to learn a whole new system.
We had this elaborately tiered plan where we would do CT [computed tomography] and MR [magnetic resonance] and print [X-ray] film, and let the doctors read film and soft-copy so they could get used to that for a while, she details. Then we would start doing CR images and print X-rays as well. After a couple of days the radiologists said, Why are we printing film? This is just silly. Lets just go for it. And so we did. We just stopped printing film.
Geuy observes that the switch to CR and PACS was not a totally painless transition, although the technologists seized the opportunity to learn the new technology and mastered its intricacies in no time.
A big challenge for us was that the technologists on the hospital side were used to order entry. On the outpatient side, we went from a hand-written requisition to order entry and CR, so we jumped off the cliff there, she acknowledges. It was a quantum leap.
But the technologists really took to the Kodak CR. We have young kids just out of school, and I have one technologist who is 72 years. And she does CR just fine!
While Geuy admits that CR has meant fewer retakes and PACS has stemmed film loss, she is not convinced that the new technology has improved productivity. However, it has enabled the two facilities to perform their work much more accurately. Of that she has no doubt.
From a throughput perspective, I dont think it is quicker, but I think our accuracy has improved. Our repeat rate has been cut in half, so in that regard we are not taking as many films and maybe patients get out a little quicker. There is a bar code reader on the CR, and we print a bar code label and put that on the requisition so that the technologist only needs to swipe the requisition under the bar code reader and theres an interface, so it will go to that patient.
Based on their experience with Kodak CR and PACS, Marion administrators in mid-July placed an order for a Kodak DR room, destined for the Marion Area Health Center. Geuy anticipates that DR will better handle the increase in volume that is expected to occur when Marion General transfers all outpatient activity to the center.
I dont think we would have considered DR out of the box, she opines. We had so much to learn, and we are still learning.
Fuji formatting finishes first
When Dominican Hospital (Santa Cruz, Calif.) went looking for CR, its managers shopped hard and chose Fuji Medical Systems USA Inc. (Stamford, Conn.).
Dominican Hospital installed two Fuji SmartCR units in its emergency department, where managers estimate the units will handle between 12,000 and 17,000 of the hospitals 42,000 annual non-CT, ultrasound and nuclear medicine exams.
As one of 47 hospitals belonging to the Catholic Healthcare West (San Francisco) not-for-profit network, Dominican is brand new to CR, having installed two Fuji SmartCR units just about five months ago. The two went into the two radiography rooms in Dominicans emergency department (ED) where managers estimate the units will handle between 12,000 and 17,000 of the hospitals 42,000 annual non-CT, ultrasound and nuclear medicine exams. The hospital also loads all portable radiology cases from throughout the facility into the SmartCR systems. Overall, Dominican performs 65,000 exams a year.
SmartCR, introduced in February of this year, is Fujis smallest CR product, with a footprint of 3 square feet. All components work together as a unit and include a flat-panel touch screen, information processing unit, image reader, workstation, image plates and cassettes.
We liked Fuji simply because of the fact that they actually record a full 1K by 1K, says Rich Crescini, Dominicans director of cardiopulmonary radiology. In other words, they have more data recorded within their film. The Fuji system also prints out a 4K by 4K image on their laser, which is the most data thats printed on a laser. We were able to give the radiologists a full-formatted image just like they are used to getting when they get it out of a radiographic film cassette. When they are comparing an old chest X-ray from a year ago on film to one done today on CR, the two essentially look the same on the format side. The difference, of course, is that image quality on CR is much better than with film-screen.
While considering the impact on radiologists figured prominently in Dominicans CR deliberations, the hospital also took care to minimize technologists concerns.
We knew CR would give them interim, preliminary view capabilities that they didnt currently have, Crescini says. When we lined up A, B and C, we wanted to make sure we didnt give the techs anything that was slower from start to initial view to finish. We found that the turnaround time with Fuji was a lot faster than what we saw with other systems, from the time that you put your charged plates into the CR reader to the time they came out in the printed laser-film format, he clarifies. Also, the time from when you put your charged plate in until you can get your preliminary view, your on-screen view of the image, that cycle we thought was much more streamlined on the Fuji configuration than what we saw with others. It was an important factor.
SmartCR = Smart move
It did not take long for Dominican to notice an improvement in workflow. In short order, SmartCR proved to be a smart acquisition.
It has had a marked improvement in the workflow being able to review the film, the dynamic range of the digital capture, being able to get a more penetrative look at an area, have an unpenetrative look at an area if you need that for any reason, Crescini says.
Other considerations were the exposure-factor differences that we encounter when reading film. In the chest, for instance, you are faced with a lot of unknown densities, he adds, describing a scenario wherein a patient with emphysema, for which exposure would be light, is being imaged for fluid and an atelectatic lung, which requires a more penetrating exposure. With CR, you have a wide range of exposure parameters. You can set your parameter and adjust that scale so you can bring the film to a level that is appropriate with one exposure. In the past you would have had to go back and make an additional exposure.
In several ways, SmartCRs small size has worked well for Dominican: Two units in two separate rooms turned out to be more economical than one larger system that would have required shuttling cassettes back and forth. Two units also allow for redundancy or backup. And since the hospital loads its portable radiography into the SmartCR, having two stations means one is almost always ready and available.
SmartCR also provides Dominican with an option that Crescini indicates had not been available even two years ago from any vendor. With the hospital evaluating CR for its main department, he likes the idea of installing a smaller-volume SmartCR specific to every room. Previous to SmartCR, his choices would have been limited to medium- and heavy-volume systems that would take up more space and cost more to purchase.
Approximately two months into CR, Dominican took another technological leap, laying the groundwork for PACS with Fujis Synapse product, which Crescini likens to a physician-review station. The hospital plans to set up review stations in the ED, the ICU and the critical care unit. Only CT, ultrasound and SmartCR images will be available for viewing in the Synapse system, making it more of a digital repository than a PACS, Crescini admits. Currently, Dominican has no film digitizer that would enable film-screen images to be entered into the system.
When you start saying, Where do you want to be with PACS? I dont think anybody has a simple answer to that question, he says. We are looking along the lines of being associated with something of a backbone type of approach, not restricting ourselves to being heavily proprietary and being able to mix and match various vendors. Fuji allows us to consider that option.
Theres that old question: If I buy CR today, in two years is it going to be trashed? I dont think so. It is a flexible system, he goes on. I think CR and DR will run congruent to each other in certain applications. What we have been able to gain from investigating DR is that it is a little more application-limited and not time-proven. It becomes a question of, where do we want to use it and what do we want to use it for and is DR going to be more limiting to us. I dont think one will ever replace the other in the immediate future.