In the era of PACS (picture archiving and communications systems), printed radiographic film is becoming the enemy. Film itself is expensive, handling it is cumbersome and prone to human error, and storing it is costly. Facilities that have converted to PACS would like nothing better than to get rid of film. They are pressing to do so. The efforts to dispense with film have been far from brutal, however. Or far from complete. For some big institutions, film remains central to dispersing images. Generally speaking, doctors in any setting who want filmspecialists in particularare continuing to get it. The efforts to cut down on film appear to be, for the most part, polite and professionally compassionate. Still, for all but specific pockets of film use, the end appears to be out there, somewhere, at an unspecified date in the future.
Gary Reed is president of a PACS consulting firm based in New Jersey. “My estimate for no film and no paper is less than 10 years,” he says. “If you extrapolate out the speed and price of electronic networks and storage space and you introduce an industry-accepted [image data] compression, this is all going to look real easy.”
Before that filmless day comes, many film-based operations will have to be phased out, many surgeons and doctors weaned from film, and many soft-copy systems installed. The price of film is driving facilities to explore nonfilm alternatives quickly. That applies to nonfilm alternatives both within and outside of an enterprise. As Reed points out, there are only four options for conveying radiological images outside an enterprise. “You can get a web browser that works, you can continue to print film, you can get a CD burner, or you can print paper.”
Increasingly, CD-ROMs are becoming the method of choice to send images to referring physicians or to give images to patients. Film costs per sheet are measured in dollars; CD-ROM costs per disk are measured in pennies. Some enterprises, large and small, are trying to use printed paper in place of printed film. Paper is also cheaper than film. But CDs seem to be favored because they retain the soft-copy format and break ground for soft-copy imaging generally. CDs are popular also because radiologists’ reports can be automatically copied onto the disks along with images, giving the recipient physicians one neat package to deal with. CDs typically have on them the necessary software and instructions to view the images, so that all the recipients have to do is pop them into the PC and start clicking.
Many institutions are using all four modesweb, film, CDs, paperto get images to those who need them. The overriding aim though is to convert to soft copy. A parallel struggle is taking place to cut down on film usage within institutions and health care groups that have PACS, but where some clinicians are still asking for or demanding hard copy. These efforts to dispense with film can go only as far as institutions purchasing computers or other equipment for specific physicians can get them to go filmless. For this story, several practices were investigated to see how they are dealing with film and the continuing need to print it.
University of WisconsinMadison
Gary J. Wendt, MD, MBA, is a neuroradiologist, an assistant professor of radiology, and vice chair for informatics in the radiology department at the University of Wisconsin-Madison Medical School. UW-Madison operates a 463-bed hospital, about six large clinics, and dozens of smaller ones, and its health organization is composed of about 800 doctors, says Wendt. According to the medical school’s web site, this physician practice group is one of the 10 largest in the country. Wendt says about 50 radiologists at UW-Madison perform about 300,000 studies annually. Wendt is well suited to oversee the radiology department’s informatics effort. He holds a BS degree in electrical engineering.
Wendt says the aim of any PACS installation should not be primarily to decrease or eliminate use of film. “The biggest reason to implement PACS is to increase efficiency and then push that same efficiency out into the enterprise,” he says. “I would use throughput and improved patient care as the justification to do PACS.” Nonetheless, reducing film use is an objective at UW-Madison.
Since UW-Madison installed its PACS in 1999 and its electronic archive a year later, film costs have dropped by more than 50%, Wendt says. What makes this reduction even more significant, he adds, is that during roughly the same time span, CT imaging volume has multiplied several-fold because of new multislice technology. “We looked at 1998 through 2002 data,” he says. “Our average CT study was less than 50 images prior to 1998 or 1 million images per year. Now our CT volume has gone to more than 7 million images per year.” The fact that the CT images are now electronically archived represents huge film savings, he adds.
To save more money, UW-Madison prints on paper wherever it can. “Paper is often better because of 3-D and the need for color, which can’t be reproduced on film,” Wendt says. “We have had very good success distributing images with paper.” UW-Madison is studying the use of CD-ROM distribution, but it has not started using CDs because of unresolved patient privacy concerns, says Wendt. “That’s literally like handing out film jackets to people. We want to make sure that the CD can be tracked for appropriate use. We will probably put serial numbers on CDs and have them checked out through the file room, just like film jackets are.”
UW-Madison doctors who want film get it. “We don’t ever put out a mandate that we are not printing film,” Wendt says. Radiologists in the system, however, read soft copy “virtually 100%,” he adds. “Right now, except for part of mammography and one inpatient chest unit, everything in radiology is online.”
The Mayo Clinic
The Mayo Clinic has its main facilities in Rochester, Minn, where it operates two hospitals totaling about 2,000 beds. It has satellite clinics and hospitals in Florida and Arizona. Bradley J. Erickson, MD, PhD, a neuroradiologist with a doctorate in physiology and biophysics, is an associate professor of radiology at Mayo. The clinic has about 120 radiologists on staff and processes about 800,000 images per year, Erickson says.
“We are actively trying to get away from film,” he says. “We have had a plain film PACS in place since 1994.” Despite this, Mayo, for now, is still printing film for most of its examinations, the exception being ultrasound, the one modality that is filmless. The clinic is in the process of selecting a new PACS vendor and intends to go filmless with its other modalities sometime this year, Erickson adds. Mayo does have a network of 12,500 EEDs (electronic environment devices), which, Erickson says, are “PC clone-type tightly managed computers.” The EEDs “have a run list of about 200 applications, and one of those is the image viewer,” he adds. “That is very heavily used. About 3,000 viewers look at 7,000 images per day.” But the EED computers are not of diagnostic quality; the EEDs are mostly being used to develop an electronic medical record (EMR), Erickson says.
One reason Mayo has been slow to go to soft copy is the film distribution system the clinic uses. With minor exceptions, film is distributed only to clinicians within the Mayo system. “It is the view here that the clinician owns the films, and as soon as we take them, they go to the patient’s home floor. We don’t have a central film repository. Radiology does that archiving only when the patient is dismissed,” Erickson says. “There is a mentality here that the clinician is expecting film.” The radiologist’s report always goes out with the film, he adds, and the film is mostly processed on dry laser printers.
But all this is changing as Mayo plans for an upgraded PACS installation. Erickson says it is the clinicians more than the radiologists who are determining how that will be done. “There is an institutional committee looking at which viewer to use,” he says. “It is the clinicians who are forcing themselves to go filmless. We [in radiology] are getting them involved in the decision-making, and we are acting as consultants.”
Elizabeth McKnight is program director for imaging at Northwestern Memorial Hospital (NMH), which is affiliated with Chicago’s Northwestern University Medical School. NMH has about 40 radiologists on staff and performs about 300,000 imaging studies per year, McKnight says. Since the radiology department went filmless with its PACS installation in 1998, it has cut its film cost by 50%. It is aggressively pursuing more cutbacks in film, and it expects to halve film costs again this year, McKnight says.
To cut back on film, the hospital is in the process of “migrating to CD-ROM only,” McKnight says. “By replacing film with CDs, we cut costs by 96% per request,” she says. “We are clamping down on requests for film. ,” she says. “We have started sending a CD with all film and asking our doctors to try it. In the near future, we intend to replace most film requests with CDs.'”
NMH has more than 80 PACS workstations on campus, including the operating room. PACS images are also available on campusvia web-PACS. “We are now piloting secure remote access to web-PACS in addition to other hospital information systems,” says McKnight.
NMH and radiology are working to assist in the deployment of technology to referring physicians to enable them to take advantage of remote access to images and patient information. “We have considered offering o buy them a printer, and they can buy their own film,” she says.
McKnight is careful to add that “we don’t want to eliminate film for anyone for whom it is essential for them to practice.” To illustrate how inventive the hospital is willing to be to accommodate doctors to soft copy, she uses the example of a surgeon for whom a special moveable cart with a PACS workstation on it was put into the operating room. “He likes to operate the PACS from the operating table by himself,” she says. “The workstation is mounted on a leashed cart that cannot be removed from the room where there is not a safety issue. The surgeon uses a wireless mouse in a sterile bag. He picks it up like any other sterile instrument. He operates the PACS himself, and he’s happy as can be.” The hospital also employs mobile PACS stations with projectors for grand rounds and conferencing. There are workstations in the doctor’s lounge and in the file room that was formerly used for film print checkout, McKnight says. “The people who work in the film printing room now burn CDs and help the physicians to navigate PACS.”
Hoag Memorial Hospital Presbyterian in Newport Beach, Calif, is a major health care provider in populous Orange County south of Los Angeles. Opened in 1952, the not-for-profit Hoag Hospital is composed of the main 409-bed hospital and six health care centers around the county. More than 900 doctors are on staff at Hoag. It has 26 radiologists who complete more than 300,000 imaging procedures per year.
Michael Battin, BS, is a former helicopter paramedic who now serves as Hoag’s information system project manager for digital imaging. Battin says Hoag has been filmless with its PACS in cardiology and radiology for the last 2 years. But film is still printed for the operating rooms preceding and? duringsurgery and all mammography is also printed on film. Film is sent to referring physicians if requested. For all others, Hoag is using a third-party solution that Battin calls a “robotic high-volume CD burner” to automatically burn images and reports from the PACS onto CDs. “We have a stand-
ing rule that we burn these images to CDs only, and patients also get CDs,” Battin
says. “Of our outside images, about 80% go out on CDs and 20% on film. We burn probably 50 CDs per day.” Films and CDs are sent to patients and doctors via mail, overnight couriers, or hand delivery, Battin says.
Battin says Hoag plans to get the operating rooms online by the coming summer. Mammography, he adds, will probably remain on film for the foreseeable future, given that the technology is not fully developed.
Like others, Battin says the real value of PACS is not film savings but efficiency in patient care. “It used to take 20 minutes to get a chest x-ray, and now it takes 5 minutes. That does improve patient care.”
Again like others, Battin makes the point that having a capacity to print film works as an important backup if the PACS goes down. “Printing film and burning CDs are key components if the system goes down,” he says. “We have created the ability to send all studies to a small server for 24 hours and print right from there.”
Three key employees at small facilities that struggle with film costs were also interviewed for this story, and they provide valuable insight into how film is being squeezed out at rural practices and why cutting back is important in these venues as well.
n Cleburne Diagnostic Imaging in Cleburne, Tex, is a new imaging center open only since June of last year. The center provides PACS imaging for patients and doctors in this town of about 25,000 southeast of Ft Worth. There are no radiologists on staff. The images are sent over T1 lines to Ft Worth where they are read and electronic reports are completed by contract radiologists using voice recognition software. These reports are electronically sent back to Cleburne.
Patti Stone, RT, is Cleburne’s managing technician, one of six technicians on staff. She says the center provides modern imaging technology to rural patients who would otherwise have to travel 40 miles to Ft Worth to get it. The center does MRI, CT, DEXA (dual energy x-ray absorptiometry), ultrasound, and routine x-ray using a CR writer, she says. It sees 20 to 25 patients per day and gets referrals from 60 to 75 doctors. Cleburne is trying hard to minimize film use by sending CDs to doctors who will accept them, Stone says. “We automatically do a CD on every patient and put the CD in a special pocket at the back of their chart. When we send out hard-copy film to doctors, we send the CD also, which comes with all the software needed to view it. There are a number of large groups where the doctors do want to look at images electronically.”
Stone says she doubts Cleburne will ever be entirely filmless. Her goal is to become 80% filmless, which, she says, “is still a good long ways away.” To get CDs to doctors, patients act as the couriers, Stone says, although mail and courier services are used occasionally. Radiology reports, which are what most doctors want to see in preference to images, are faxed to them, Stone says.
n St Thomas More Hospital, Canon City, Colo, is licensed for about 55 beds, has approximately 25 physicians on staff, and employs two radiologists. Curtis Harlow, MD, is one of the radiologists. Harlow says the hospital is completing a mini-PACS installation, but he and his partner have already been reading soft copy for 6 months. To save film, the hospital has been printing “little postage stamp pictures just for the archive” and printing normally for everything else, Harlow says. The electronic archive will go online in a few weeks.
Harlow says in the short term, Thomas More will continue to print film but will also begin burning CDs on applicable modalities within a few weeks. “In the long term, we want to do away with film completely, but that’s probably 5 years away.” Harlow says that is about when he expects to be able to digitize plain film, which until then will have to be printed. He hopes use of film can be cut by 25% within 6 months of the start-up of PACS. In the 18 months after that, he hopes to cut another 25% off film volume. “Maybe in 2 or 3 years we will say to our doctors, Read soft copy or nothing.’ For now, that is the weaning strategy. We have not at all tried to prepare physicians to go to soft copy.” He says one stumbling block probably will be the price of modern computers and broadband lines for some doctors. “I think only about 25% stop by to look at images now,” he says. “Most of them are just reading reports. We may eventually try to put a video display in surgery, but right now I don’t think that will go very far very fast.”
Harlow says he himself has become a hard-line soft-copy convert. “I believe I read faster and more accurately. With CTs there are so many slices on the light boxes it’s easy to skip a slice. When you scroll through them soft, you can’t miss a slice. One of our workstations went down recently for about 10 days. It was just terrible. It made me very anxious.”
n Tahoe-Carson Radiology, Great Basin Imaging operates four outpatient imaging centers in and around Carson, Nev. The company has operated a PACS in conjunction with 125-bed Carson-Tahoe Hospital for the last 6 years. It employs seven radiologists. It has only CT and MR online now, but it is opening a new center that will be totally filmless, according to Debra Platt, the company’s operations director.
Platt says referring physicians now can have images however they want themon film, on paper, on CDs, or over the web. She says about 70% of doctors view on the web, but that orthopedists, the heaviest referrers, usually want film. A few doctors want printed paper, she says. “Some don’t care what it costs us if we have to print film, while others understand it is hard for us to bear that cost. It is a huge cost. We spend about $125,000 per year on film. By going filmless in our new facility, we hope to reduce that to $30,000.” In the new facility CDs will be burned routinely, she says. While some doctors have welcomed soft copy, she says, “not as many physicians as we hoped for have been willing to let go of film.”
The Future of Film
There is uniform agreement that pockets of film will probably always exist. Film printers will also function as emergency backup to electronic systems if and when they crash. But the landscape for printed film definitely has already changed. “The printer manufacturers are all trying to guess what their play is going to be,” says Reed. “The printer people are looking really hard at printers designed to be adjuncts to PACS. They are bridging into digital imaging.”
In the longer term, Reed says systems that can communicate with each other will carry the day. “The play in the long run may be one of the telecommunications giants that will also be your EMR company, your PACS company, and everything else. They have the communications lines and data repositories already, and they’re already very deep into the hospitals. All the providers [vendors] are going to have to work with each other on compliance to [uniform] standards and open systems. That’s the only way it’s going to work.”
George Wiley is a contributing writer for Decisions in Axis Imaging News.