Even as PACS, with its promise of a filmless environment, continues to penetrate hospitals nationwide, the printer is holding its ownseeing its role not being eliminated but changing in the face of new technology and the needs of departments and referrers.

In addition, the advances in printing technology from wet processing to dry laser printers have made printers smaller, easier to maintain, and ultimately cheaper.

But even in departments with similar practice and procedural landscapes, the way printers are used and deployed varies from environment to environment.

The Cleveland Clinic and Hendricks Regional Health (HRH), Danville, Ind, are large organizations that have successfully implemented a PACS system but have seen its printing needs vary because of the geographic and technological realities of their individual organizations.

Open High-Field MRI & CT of Westchester, Larchmont, NY, also implemented a PACS system in the hopes of eliminating the need for a printer altogether, something that could not be achieved because of the medical culture of its region.

The 750-bed Baystate Health System (BHS), Springfield, Mass, still relies exclusively on its system of eight dry printers to meet the needs of referrers and its radiologists, while planning to implement a PACS system of its own.

For John Litchney, department of regional radiology administrator for the Cleveland Clinic, even with a PACS system in place, there is still a juggling act to perform in order to effectively position printers throughout the large metropolitan health system.


Spread over 17 buildings, the Cleveland Clinic’s radiology department offers the full gamut of imaging modalities. The department has a centralized printing arrangement in each grouping of equipment with, in some cases, up to four modalities running through each printer. In general, the ratio of imaging machines to printers is about 3:1, says Litchney.

With the implementation of its PACS system, printing needs have dropped by about 65%. But even with the lower print needs of the department, Litchney has specific printer requirementswith speed at the top of the list. “The faster we can get [printing] done, the better,” he says. “As far as the other requirements, it’s individualized to the purpose we’re trying to serve. So, for instance, there are some studies you need color for, and for some, it’s not necessary. So, it’s what printer fits the application best.”

With printers being overwhelmingly dry and the footprints getting smaller, space considerations have been alleviated somewhat for Litchney, who cites construction costs of $125 a square foot. There is also the nuisance of planning for the plumbing and drains required in wet printing. “Now that’s almost a consideration of the past,” he says.

Maintenance is handled through a service contract with the printer vendor. If a printer does go down, images can be diverted to another printer. Litchney has built redundancy into the print network, holding on to a few of the department’s old wet printers just in case they are needed. “We don’t throw out everything, so if you have to go back to printing film because [the PACS] goes down&you always want to have a redundant system,” he says.

When purchasing a printer, Litchney looks at both the tangible and intangible. “The main things [to consider when buying a printer] are the initial cost of the product, the cost of the media that goes through it, and the cost of the service agreement,” he says. “Obviously, in medicine what is more important and is often overlooked is the intangiblethe uptime, the availability of the service people to correct the problem, and the reliability of the equipment. I think most people are willing to pay a premium to do the best they can to ensure things don’t fail.”

As at the Cleveland Clinic, Hendricks Regional Health has implemented a successful PACS system and has seen its printing output also drop by about 60%. Its need for printers stems from the fact that the technology available to referrers has not kept up.


Hendricks implemented a PACS system at the behest of its referrers, and it archives all the modalities, including CR, DR, CT, ultrasound, and vascular ultrasound. However, the health system hit a snag with the local cable company. “Our cable company hasn’t been real cooperative in helping some of our physicians get high-speed access. You just can’t look at digital images over a 56K dial-up, so that’s probably created more problems for us than about anything,” says Stan Metzger, MBA, RT (R,N), CNMT, RDMS, administrative director of radiology at HRH.

Among its current print requirements was a need to standardize film size to 11 x 17 inch and 10 x 12 inch and have the ability to sort the film. The department has two printers, which are centrally located. Printing is split evenly between the two printers. This has helped efficiency and speed. “Nobody is left standing there waiting,” says Metzger. “The throughput is really great.”

Metzger says that if he had to do it again, he would have purchased only one printer, even if that means eliminating redundancy in the system. “These things have been amazingly reliable,” he says. “We’ve had them almost a year, and they have broken down only once, and that was [due to operator error]. We’ve had almost zero downtime.”

Maintenance is handled by the vendor. The service contract includes phone support.

When considering a printer, Metzger looks at cost and throughput, like Litchney, and also image quality.

While Metzger acknowledges that he still needs a printer, David Stemerman, MD, medical director of Open High-Field MRI & CT of Westchester, had once hoped he had left printers behind for good. He quickly found that he had not.


Stemerman had implemented a PACS system even before the imaging center had opened its doors, and had no plans to offer a printed study. He quickly found out that he would have to buy a printer because referrers demanded their patients’ studies on film. “I’m in an area where a lot of the physicians are older. The original plan was to be filmless and, if people needed a copy, put it on a CD,” he says. “But the demand was too great [for films].”

Finding himself in immediate need for a printer presented Stemerman with a challenge. He had to purchase a printer that would both meet his referrers’ demands and fit a very small space. “The major thing I was looking for was the smallest footprint possible, because, when we designed the center, the architect never designed it to accommodate a printer,” he says. “The reason I went with the one I did was because it had a small footprint and it had multiple printing capabilities where you could print on paper or film and various sizes. And the bonus was it was the cheapest printer out there.”

Stemerman prints both CT and MRI studies to the black and white printer and has had little problem with both throughput and downtime.

Entire studies can be printed by Open High-Field MRI & CT, Stemerman says, on both regular and photographic paper. Summaries can also be prepared as well.

Stemerman adds that some referrers want it both ways. “I get a lot of requests [from referrers], I want to see the images on PACS and I want to give copies to the patients,'” he says. “Doctors seem to want everything whether they use it or not.”

Open High-Field MRI & CT handles most of its minor problems internally or through the vendor’s customer support line. More serious problems are handled by the vendor through a buy-back program Stemerman signed with the company. “When something breaks, there is no fixing it; the company just sends you a new one by FedEx the next day,” says Stemerman. In the 2 years he has had his current printer, it has broken down oncecausing only a slight inconvenience to personnel and referrers.

While Stemerman is on one end of the printer spectrumhaving a printer only because referrers demand itthe other end of the spectrum is represented by Baystate Health System.


Since the 750-bed health system does not have a PACS system yet, Baystate Health System has to rely on its network of eight printers to deliver images to the department’s radiologists and referrers.

As Baystate is a level-one trauma center, its imaging modalities run the gamut from x-ray to CT to MRI to nuclear medicine to ultrasound. All imaging is black and white and printed primarily on 14- x 17-inch film. All printing is dry except for x-ray, which still uses wet processing.

Even though he still works in a print environment, Michael Favreau, director of radiology and ambulance services, saw an improvement in the efficiency of dry printers over the wet ones. “What I enjoyed first when [dry] printers became available was getting rid of all the pollutants of a darkroom and all the inefficiencies of a darkroom,” he says. “There are environmental concerns, footprints were smaller, so there were a lot of benefits going to these dry printers.”

However, the most important requirement is the multi-sorter function. “One thing that has helped us too is the multi-sorters on our printers, designated by the exact machine it comes off of, so the techs don’t have to rifle through the whole stack,” says Favreau. “That has been a huge, huge benefit of the multi-sorters. It you didn’t have that function, then I think we’d have more printers in the department.”

The printers are all networked, but arranged throughout the health system convenient to the imaging equipment to which they are dedicated. For instance, there are five ultrasound machines set up on one printer and two MRI units on another. If a printer goes down, however, printing can be diverted to another printer. Favreau adds that there is a continual reassessment of printer locations and distribution.

Downtime is rarely an issue, says Favreau, but the department does have the benefit of internal and vendor support. In addition, the medical physicists on staff help to keep things moving.

The improving sophistication of CT has impacted the efficiency of the department. “My initial print strategy in location and number of printers was impacted quite heavily with the advent of installing multislice CTs, so therefore our efficiencies were lost; we’re just waiting for PACS to eliminate that,” says Favreau.

In the next 18 months, Favreau expects to implement a PACS, which will dramatically curtail his need for printers from eight to two. “The only printers I expect to keep will be located in my film library for what we deem necessary for printing,” he says. “We believe there will be occasional requirements in addition to burning CDs for people.”

There is little doubt that the role of printers in radiology departments is changing, but that, even in the face of PACS and the increasingly computer-savvy radiologists and referrers, there will probably always be a role for the printer in the radiology department. “Everyone wants to go filmless. I think there’s a certain point you can reach in that. However, 100% is a lot. There’s always going to be room out there for printing images,” says the Cleveland Clinic’s Litchney.

The question of how much longer the printer will remain a part of the imaging department is not something that will probably ultimately be left to the radiology department itself, but to the referrers. “Radiology doesn’t need film, a referral group needs the film,” says Litchney. “Theoretically, radiology could go filmless tomorrow.”

Chris Wolski is associate editor of Decisions in Imaging.