f02a.jpg (14545 bytes)The advantages of digital radiography technology are becoming well documented, but facilities considering adopting DR or CR (computed radiography) want to know who benefits the most from DR and how much the benefits improve their radiology department.

Advantages, such as increased productivity, long-term cost savings, remote access to images, and reduced retakes, can be seen in any DR-touting facility, but early adopters indicate they are even more visible in a large, busy radiology department.

Economic benefits
Cost justification is perhaps the biggest question mark with DR systems. Are the many benefits of CCD and flat panel-based DR enough to justify the inflated list price of the average DR unit?

Experts agree that a DR purchase will make its list price back in advantages soon enough, but it stands to reason that a larger facility with more patient volume will recover the investment sooner than a smaller facility.

Reducing the cost of film alone at a large facility makes a DR environment more appealing. The expenses of producing, displaying and archiving X-ray films at a larger facility can mount much more quickly than at a smaller hospital or clinic. More patients mean more film, chemicals and processing; it is a simple cost-per-patient equation.

When that model is compared to DR with its one-time acquisition cost and reduced processing and archiving costs, CFOs will argue that the more patients that can file through a DR room, the sooner they will make back the DR investment.

As larger healthcare facilities become more geographically diverse, simply getting films to referring physicians and specific departments can become a cost issue as well. While a DR system and PACS will go a long way to cure that woe, a larger facility typically will require more workstations and review stations than a smaller or more centralized facility.

That was the issue at 950-bed St. Luke’s Episcopal Hospital (Houston). St. Luke’s was an early adopter of the DR-1000 chest system from Direct Radiography Corp. (DRC of Newark, Del.). While the facility has yet to install a PACS, that project is high on the list and will start in the near future. For now, medical images are reviewed on softcopy and printed for archiving and distribution.

According to David Sack, administrative director of radiology at St. Luke’s, his facilities are clearly seeing the benefits of DR, but there are many more to come. Speed of acquisition and reduced retakes are enjoyed now, but Sack says larger facilities have more of a problem with lost films than the average smaller facility, which will make a PACS and archive more valuable. For one, patients tend to travel more at a larger facility to see different specialists, making timely distribution of images difficult.

Similarly, the size and geographic scope of the Cleveland (Ohio) Clinic Foundation made the electronic distribution of images a big advantage. However, the complexity of the average case at a larger, more well-known facility, such as Cleveland Clinic, also increases the value of a DR system and PACS.

“It’s not unusual for our patients to see several clinicians in a hospital or outpatient visit,” says David Piraino, M.D., staff radiologist and section head of computers in radiology at Cleveland Clinic. “So, for us to get a physical film to everywhere a patient has been in his or her visit can be difficult. Electronically, it is much easier to do. At larger facilities, where you tend to have more complex cases, that is an advantage.”

The presence of residents at larger facilities sometimes complicates the issue because residents tend to “hide” a film to show it to the attending physician.

Testing one-two
The resources at a larger facility can come in handy when installing a new technology like a DR system. As one of the beta test sites for the DR-1000, St. Luke’s found itself with one less radiography room at times early in the testing process when the system ran into problems. It was here that Sack found the biggest advantage as a larger facility with several radiography rooms.

Where Is the Advice Coming From?

Representatives from the following facilities were queried for this article on the advantages of using digital radiography systems in large healthcare facilities:


DR System(s)

St. Luke’s Episcopal Hospital
(Houston, Texas)

DR1000 from DRC

The Cleveland Clinic Foundation
(Cleveland, Ohio)

DR-1000 from DRC;
Canon CXDI-11;
Siemens MultixFD???

Kaiser Permanente San Francisco Medical Center
(San Francisco)

Canon CXDI-11 and
two Canon DR retrofits

University of Texas Medical Branch
(Galveston, Texas)

Two Swissray ddR Multi-Systems

“Smaller facilities don’t have the flexibility of having a room down for repair or an upgrade,” he says. “At our facility, we had the flexibility with other rooms so if we had the DR room down for a week, it wasn’t disastrous. At a smaller facility that could be excruciatingly painful.”

Larger facilities also serve as more efficient testing grounds for new technologies because of the high rate at which patients pass through the radiography department.

“Being a larger facility, we can get more patients through the system faster than a smaller facility, which makes us a better facility to test new technologies,” Sack explains. “I can give the manufacturer more feedback with the system faster than a smaller facility can.”

The Cleveland Clinic is adept at testing and evaluating new equipment and may have one of the most diverse DR lineups in the country. The facility is using DR systems from DRC, Canon Medical Systems (Irvine, Calif.) and Siemens Medical Systems Inc. (Iselin, N.J.).

“We’re used to testing prototype units and evaluating technologies that are just released,” says Piraino. “We evaluate new CT scanners and other devices and the testing of the DR system has been very similar to that. I would say the DR units we’ve had – while they’re not plug-and-play – they’re pretty much put-in-and-go, and the difficulty of moving to that hasn’t been too great.”

Radiography was the last modality to be brought onto the Siemens PACS at the Cleveland Clinic, so the transition to reading digital X-rays was much less of a transition for the clinicians as it is at some facilities. The PACS at Cleveland Clinic includes 27 diagnostic review stations and 150 clinical review or smaller diagnostic review stations in various locations. Last year, the PACS archived more than 200,000 exams.

Raul Reyes, director of radiology services at University of Texas Medical Branch (UTMB of Galveston, Texas), says the higher number of residents at an academic institution can put more focus on in-house services at a facility using DR. In 1998, Texas became an early DR adopter when it installed two DR systems from Swissray International (New York), one in the orthopedic department and another at an off-site criminal justice facility affiliated with UTMB. Currently, UTMB performs 15,000 DR exams per year with the orthopedic system alone.

Reyes explains that as an academic hospital, the Texas facility sees new residents coming into the department to use the DR systems, many of which have no experience with them.

“The majority of the problems in the beginning are operator error,” he says. “So, our in-house techs are trained to see if it’s just someone pushing the wrong button, or if it is a real problem that needs to be addressed by the manufacturer.”

Reyes says one service call at UTMB for a downed workstation turned out to be something extremely simple – the screen saver had turned on. Situations such as those make an experienced in-house service staff a necessary first line of defense in DR repair.

Installation bugs
The physical installation of a DR system – or any major equipment – is no small task and installing it during a major construction project can complicate the issue further. The issue begs the question: Is a larger facility more equipped to deal with such a major undertaking?

Three years ago, Kaiser Permanente San Francisco Medical Center was planning the design of a new outpatient imaging facility that would replace one that was not deemed seismically safe. Planners at the time budgeted for new analog radiography equipment in five rooms in the new building to replace five rooms in the existing building. However, as the new building took shape, hospital officials began to look into a digital radiography system from Canon and decided that going digital could mean cutting back to three rooms.

Kaiser’s chest room has a refurbished generator from Shimadzu Medical Systems (Torrance, Calif.) coupled with the Canon CXDI-11 upright detector. The other two radiographic rooms each use GE Medical Systems (Waukesha, Wis.) generators with Canon digital detectors.

The installation of the new systems took place while the new outpatient facility was built around them. Roger Boots, vice president of sales and marketing at Diagnostic Imaging Inc. (Jacksonville, Fla.), the distributor that handled the installation, feels that being a larger facility, Kaiser Permanente was at an advantage, because it was used to major construction projects and equipment upgrades.

While the construction process itself didn’t prove too distracting, the IT issues with the installation got somewhat complicated and the bureaucracy of a large health system loomed, according to Boots.

“[Kaiser’s IS people] were not aware until the last minute just how much data we’d be putting onto the network,” Boots explains. “Kaiser has national ordinances about what can go on the network and what can’t. We had to get waivers from the national ordinance board to get onto the network in the first place. It was quite an ordeal.”

Boots says the facility was at an advantage having a high-capacity network in place, but having to change out of Kaiser’s existing model made it a challenge. He feels a smaller facility may be more flexible on the issue.

Boots says the clinicians at the facility noted almost immediately the lack of patients in the waiting room for the busy facility, which processes an average of 170 patients per day.

Piraino says there were some informatics and related issues to deal with at the installations at Cleveland Clinic, especially getting the HIS and DR systems to talk with each other. But does being a larger and more research-oriented facility provide an advantage in terms of IS and network infrastructure? While size isn’t necessarily a prerequisite for having a strong network infrastructure, the two typically go hand in hand. The larger facilities usually require a stronger network backbone for the amount, frequency and size of digital studies sent across it.

Back in 1998 when the two Swissray DR systems were installed at the 600-bed UTMB site, planners were concerned with the effect DR images would have on the hospital’s network. At a large facility, the size and number of digital images sent across a network is a serious concern. Rather than greatly impacting the rest of the facility, the DR systems were put on an isolated network as an added precaution. Like many other facilities, the IS department at Texas had no idea what to expect from DR images and were likely to have underestimated the size of the digital images and the frequency with which they would be produced with a DR system.

A larger, more geographically diverse facility has to think of new ways to get its DR images to the different users on the network. UTMB has more than 170 nodes on its PACS network, including 60 PACS workstations. In the coming months, the facility plans on distributing PACS workstations to its outpatient facilities. As part of that project, organizers are planning on utilizing Web servers to offer quicker access to images on the archive.

The disadvantage of being a large, more geographically diverse facility or system comes when physically installing the clinical review stations for a full PACS. Piraino says there are more than 1,000 locations at which physicians may need access to the PACS and getting those review stations up and running takes time – and nobody wants to be the last on the list.

Coming to a (high) resolution
The cost justification of a DR system is something not many clinicians like to think about, but administrators are forced to dwell on. Does that cost justification seem more realistic in a larger facility?

According to the DR sites polled, the economic and workflow benefits of a DR system are more clearly demonstrated in a larger facility. When exam times are trimmed on a per-exam basis, the greater the number of exams, the greater total time saved or the more total exams can be done in the same time frame. That’s the simple economic reality.

“When you go to this technology, you would like to be able to do more exams in the new room than you did in the older environment to keep costs the same or less,” says Piraino. “So you need to be able to provide that volume in the locations you put those things into; volumes of 100 a day or more. Having that volume helps so you can really take advantage of productivity gains.”

Certainly there are advantages to using a DR system at a smaller facility, and next month Medical Imaging will look into those benefits in more detail. end.gif (810 bytes)