DR Finds Its Way to Smaller Hospitals

Digital radiography is slowly but surely gaining installations and with that, the technology is finding its way into smaller, community-based facilities. But purchasing, installing and using a new imaging technology is not an easy task for any healthcare institution. Even the most technically advanced academic and research institutions encounter problems with new technologies and smaller facilities that aren’t accustomed to the “latest and greatest” systems may find the process even more daunting. Are there things that a small healthcare facility can learn from its community-based brethren in moving to the digital world? Absolutely.

Not-so-deep pockets
The cost of a DR system is the most often cited hurdle keeping smaller facilities from purchasing a DR system. Typical budgetary concerns faced by a large hospital system are amplified at a smaller healthcare facility. But some manufacturers, eager to show off their technologies in all types of facilities and keep up with the competition, have provided flexible payment plans to better accommodate the early adopters at smaller facilities. Manufacturers are starting to realize that word-of-mouth marketing (via installations) and overall vendor reputation may be more valuable than the marketing brochures and advertising blitzes.

William P. Shuman, M.D., medical director of radiology at the 166-bed Evergreen Hospital Medical Center (Redmond, Wash.) and clinical professor at the University of Washington (Seattle) says he found Canon Medical Systems (Irvine, Calif.) very accommodating during the purchase and installation process of Evergreen’s DR system.

Evergreen is currently using Canon’s CXDI-11 digital bucky chest and CXDI-22 digital bucky table in one radiography room and a second digital CXDI-11 in another room. By paying cash for the systems, Evergreen was able to work out a better deal with Canon than it originally anticipated.

“Canon was very interested in breaking into the [DR] market and they gave us an extremely favorable price,” Shuman reports, without revealing the actual cost. Other small facilities have reported similar flexibility in these early days of the digital X-ray market.

In the future, the retrofit option for DR may help to open the market even more for smaller facilities, but to date, the retrofit market is still shaping up and sales are not making a major impact. In fact, the number of U.S. installations can still be counted on one hand.

Image by numbers
Clinical benefits aside, the economic savings and efficiencies gained with a DR system are most often dependent on the number of patients that go through a department. When considering benefits like increased throughput, elimination of film and processing costs and easier access to images, it stands to reason the greater the number of patients, the greater the total cost benefit in terms of dollars.

But smaller facilities are quick to point out that the savings they experience are similar to the larger facilities when viewed in terms of budget percentage. While the total amount saved per month, week or day may be greater at the busier facility, the elimination of film and FTEs gained with a digital system can be judged in terms of budgetary percentage and justified over a longer, but still calculable, period of time.

For example, the amount of money spent on film processing for a 700-bed facility will be a larger dollar amount than that of a 200-bed facility. But in terms of percentage of the overall radiology budget, which is most likely smaller at a smaller facility, the savings may be similar. And that’s the figure that’s important to administrators considering a DR purchase.

Productivity gains achieved with a DR system also can be measured in budgetary percentages. For example, Shuman reports seeing a 40 percent increase in productivity from his technologists with the new DR systems, which is a statistic any hospital administrator would find favorable.

The VA Medical Center in White River Junction, Vt., is a 60-bed inpatient facility with a busy outpatient radiology department. Jim Lawrence, radiology manager at the VA, says the throughput of the DR1000 unit they’ve installed from Direct Radiography Corp. (DRC of Newark, Del.) is not as crucial on a day-to-day basis at his facility as it would be at a busier facility, but the streamlined exam times do come in handy during busier times of the day.

“Depending on the referral patterns, you might get a number of patients at once and the improved throughput really helps then,” Lawrence says, adding that the HIS/RIS interface capabilities mean that the VA’s single tech doesn’t have to bother with inputting patient demographic data, which is a great advantage during busier times. “We’re able to facilitate the care in that room even as a small facility with only one tech, no matter what the referral rate may be.”

Elbow room
Making effective use of space is often a higher priority in a smaller institution and the early DR adopters feel the workspace efficiencies gained with the technology go a long way. For example, radiology department officials at the VA Medical Center’s outpatient facility saw a definite cutback on hallway consults after the new DR system was up and running. Lawrence says the workflow patterns of the radiology department with a film-based system meant physicians were retrieving films and “bumping into” patients as they found them in the hall, rather than being able to meet directly in their office.

“One of the goals of the renovation project and the installation of the DR [system] was to improve the care and make efficient use of the physicians’ time,” Lawrence says. “We wanted to redesign how exam rooms were accessed, find out how the patient flow worked, and keep the clinicians out of the hallways. Hallway consults were occurring and we weren’t accurately capturing patient encounters.”

The VA is currently still printing the film for the patient to take back to the clinician’s office, but there are hopes to eventually tie into the hospital network and give the physicians the image on their desktop as well as offer it to the radiology department at the same time. That way a patient can walk from an exam room to the clinician’s office and find the doctor reviewing the image.

With a three-DR system configuration, Evergreen has been able to concentrate all of its plain film work into the two DR rooms, freeing up a good amount of space in the radiology department and allowing the completion of some long-awaited projects. Shuman says the department has already installed an additional digital fluoroscopy suite and moved inpatient ultrasound into the main department next to the emergency room with the additional space. Those are both projects that would have required major construction if DR wasn’t introduced.

“And we took another plain film room and turned it into a CT suite so now we have two CT scanners working side by side,” he says, adding that the lack of construction for that space has saved the institution serious time, money and headaches.

In Hawaii, square footage is of the utmost concern and perhaps no one knows this better than Donna McCall, director of imaging services at the 250-bed Kuakini Medical Center (Honolulu). Kuakini installed two DR systems from DRC in April 1999 and a third in March this year. One of the primary motivators for the move to DR was electronic storage of images to eliminate a film processing room and storage space.

“The electronic archive is definitely important at space-restrictive facilities,” she says. Kuakini is partially utilizing a PACS now, including an archive, print network and two workstations and plans to expand the PACS in the future.

Manufacturers also are catering to the lack of space with new products that can be integrated easily into an existing department with minimal disruptions. One example of this trend is Swissray International’s (New York) ddRCombi system, which is designed to be mounted from a ceiling suspension for use in a crowded setting including an emergency room. The emerging retrofit technologies also are considered a good fit for space-conscious departments but, again, the market is too young to provide adequate reviews.

Keeping up with Dr. Jones
Healthcare today is big business and, like it or not, a small hospital has to do whatever it can to maintain a competitive edge. While a small facility may be at a disadvantage in terms of name recognition and variety of specialty services provided, purchasing a cutting-edge technology like DR can go a long way towards establishing a facility as a “technology leader.”

“Having DR does carry a little more weight from a marketing prospective,” McCall says. “We’re the only facility on the island that has one.”

The 200-bed Diagnostic Center Hospital of Houston has experienced the competitive aspects of healthcare firsthand. Now part of Methodist Health System, the facility is affectionately known in the system as a “best kept secret” in Houston. While that may be a compliment to its services, Robert Martinelli, radiology manager at Diagnostic Center, feels the facility can now market its DR capabilities to let the best kept secret out of the bag and draw in more patients.

The Diagnostic Center is the first U.S. installation of the Digidelca-C digital chest radiography system from Nucletron B.V. (Veenendaal, The Netherlands). Being an early adopter of a technology like DR has advantages. It gives the facility the chance to market itself as a technologically advanced facility in the competitive healthcare market and, in Diagnostic Center’s case, gain some attention from its parent organization. It also means representatives from other facilities considering a DR purchase are coming to the facility to see the new technology in action.

Entertaining the troops
In addition to the more measurable advantages a DR system brings to a smaller healthcare facility, there are some less obvious, but equally important, reasons for making the purchase. For example, Shuman says the DR technology is directly responsible for a big morale boost within Evergreen’s radiology department and has even been credited with the increased retention of technologists in a time when such “intellectual resources” are in high demand. Shuman said he’s seen a dramatic shortage in radiologic technologists in recent years, a trend that has been recently confirmed by the American Society of Radiologic Technologists (Albuquerque, N.M.).

“Technologists love working with this system,” Shuman says. “I’ve had two technologists who said they have received better job offers for more pay that are closer to their home, which they turned down because they want to stay and work with this system. That may not be true when everyone has a digital system, but for the next couple of years at least it will make a big difference for us.”

And keeping the same technologists on staff with a new technology increases the productivity of the radiology department and patient satisfaction, making the facility a more competitive player in its market. Losing an experienced technologist at a small facility with a new technology means promoting a less experienced one to work with the system or bringing in a new, more experienced tech that is not familiar with the hospital or, most likely, not an experienced DR user.

Stones in the road
The major drawback to implementing a new technology like DR at a smaller facility is that most smaller radiology departments aren’t accustomed to using new or cutting-edge technologies. There is typically a period of transition for technologists and radiologists with a new system and the reports on digital radiography range from smooth transitions to near chaos.

Martinelli says Diagnostic Center had to deal with the typical technical hurdles in getting the Digidelca-C up and running. While there were other rooms to divert patients to during the occasional expected down times in the system’s early testing, it was an inconvenience at times and not the best marketing for a facility. Nucletron planned wisely for these events and had trained a technician at a Houston-area service provider who is able to get to the site and troubleshoot as needed.

Diagnostic Center also saw a division among its radiologists with the introduction of DR. According to Martinelli, the younger radiologists have embraced the DR technology and the older ones have shown more reluctance to begin using it. But that’s a transition every facility must work through on its own.

McCall says she was lucky as Kuakini had a very smooth and even enthusiastic adoption of DR.

“The radiologists and technologists adapted well to the technology and have become very proficient at using it,” she says. “I believe everyone’s exposure to computers, Windows environments, and point-and-click applications made them more accepting of the equipment and its requirements.”

Shuman says Evergreen is evaluating PACS vendors now and hopes to have one installed in the next year, at which point radiology will move to soft-copy diagnosis. While he’s not planning on forcing radiologists to read soft copy from the first day, Shuman does feel softcopy diagnosis provides enough clinical value to warrant the transition. But Evergreen may be uniquely qualified to move to digital imaging than other hospitals its size.

“The address of this hospital is in Redmond, Wash.,” Shuman points out. “The other major organization in Redmond is Microsoft Corp., so Redmond is a community where 89 percent of the people use the Internet.” That computer familiarity translates over to the healthcare setting easily, Shuman says.

But effectively managing the changeover period to digital diagnosis can be tricky if certain radiologists resist the move to digital images. Martinelli’s plan is to let those who want to diagnose from soft copy to go forward with that and let those more comfortable with film continue in that mode for the foreseeable future. Eventually, he feels the older radiologists will either come around to digital diagnosis or retire from the field. As for storage, he plans to store the electronic images on CD until he can get a PACS archive installed in the next year or two.

Learning from each other
In short, every healthcare facility, no matter what size, shape or specialty, will have its own issues in purchasing, installing and using a DR system. The one common piece of advice from early adopters is clear: Do your homework. There are enough installations now that potential DR adopters can visit and interview a hospital similar to it in size and patient flow that is now using DR. Ask questions, discuss problems and get hints.

Before going live with Evergreen’s HIS/RIS interface, Shuman made a point to visit the Cleveland Clinic Foundation (Cleveland), which has DR systems from three different manufacturers running (including one from Canon which Evergreen has). Shuman acknowledges the differences in size between the facilities, but feels that Cleveland Clinic has seen it all and is the best model for his radiology department.

“We’re operating on the same hardware they are, we have the same RIS,” he says. “Their software works fine there, so we’re going to literally copy it and install it.”

Healthcare may be getting more competitive in the eyes of the administrators, but in the departments, most clinicians are still doing whatever they can to help the patient/customer, including beg, borrow or finance new ideas and technologies from one another.