Leonard J. Benyak (left) and John S. Bremer, DIANAssociates, Severna Park, Md

In the late 19th and early 20th centuries, US immigration officials at New York City’s Ellis Island processing center devised a quick method that was used to screen newly arriving immigrants for signs of tuberculosis (TB) and other contagious respiratory diseases. New arrivals were shown a flight of stairs and told to walk up, turn around, and walk back down; anyone who began coughing or wheezing at the end of the exercise was identified as a TB risk and pulled to one side for examination by a physician. It was far from reliable, but it was the best that the authorities could manage at the time.

Years passed, and Ellis Island was eclipsed in prominence by numerous Immigration and Naturalization Service (INS) intake facilities. TB detection techniques, meanwhile, became vastly more trustworthy following the introduction of diagnostic imaging. Unfortunately, while film-based radiography has provided an excellent means of assessing probable tuberculosis, it has been considerably slower than the stair-climbing method. Typically, immigrants had to stay at the crowded INS intake centers while waiting for their chest studies to be received by radiologists, interpreted, and reported to INS personnel.

All that is changing now, thanks to the recent INS implementation of direct digital radiography (ddR) systems. These state-of-the-art imaging devices enable a chest examination to be completed in less than a minute, with the image?in electronic format?delivered to a radiologist in about the same amount of time that it took the Ellis Island immigrants to go up and down the famous staircase.

Equipping Multiple CENTERS

Considering that the radiologist is located at the University of Maryland Medical System, Baltimore, that constitutes rapid image transmission. Philip A. Templeton, MD, former chair of the department of diagnostic radiology at the University of Maryland School of Medicine and founder and CEO of Templeton Technologies, Severna Park, Md, a telehealth company, says, “It is a very intriguing project for us, especially in light of the fact that the images are being transmitted to us from what are, essentially, economically austere, geographically remote, limited-access, personnel-challenged environments. Currently, there are multiple INS intake centers producing digital radiography images. Each of these sites has been supplied with a Swissray ddR system and is linked to the university via secure private network provided and administered by Eagan, Minn-based WAM!NET Global Healthcare. The screening program itself is operated for the INS by DIANAssociates Inc, Severna Park, Md, a digital image-acquisition network company that offers turnkey telemedical health care solutions, including teleradiology and other patient-contact telehealth modalities (such as congestive heart failure monitoring systems).

The University of Maryland Medical System was a logical choice as the partner responsible for interpreting the images due to its commitment to cutting-edge digital technology. “We are an all-digital radiology enterprise,” Templeton says. “When I became the chair of the department several years ago, my goal was to transform it into a world-class environment for radiology, with bigger and better facilities, the finest new technologies, and an excellent radiology faculty and staff. That is a goal that has, I am pleased to say, been met.” Indeed, the department of diagnostic radiology provides comprehensive diagnostic imaging and treatment services throughout the University of Maryland Medical Center, the main hospital in the medical system and the facility in which the department is based. The University of Maryland Medical System is a private, not-for-profit hospital system with 1,907 licensed beds and more than 9,000 employees. It provides a complete range of inpatient and outpatient services to over 300,000 patients per year. In the radiology department, frequently seen patients include those with suspected cancers, infections, vascular problems, gynecologic and obstetric disorders, trauma, or a need for presurgical imaging. Radiology services cover the range from organ-transplant imaging to positron-emission tomography for evaluating cancer and other abnormalities.

The department also is aggressively engaged in research on topics such as MRI exploration of changes in metastatic liver lesions, particularly following chemotherapy and radiation therapy; breast and cardiac MRI; CT and MRI for trauma victims; radiolabeled angiogenesis factors; endovascular cerebral-aneurysm treatment; and stent grafts for vascular pathology.

ADDinG Direct digital radiography

All imaging modalities are found at the University of Maryland Medical System except one: ddR. That lack will be remedied, however, by spring 2002. At that time, the university will take possession of three ddR machines. Two of these will be installed in an ultramodern emergency department on which construction is now nearing completion. The other will be set up in the radiology department’s core area. Output from the trio of ddR systems will, in all instances, be read as soft copy on workstation monitors. “We do not print anything, around here, as part of the diagnostic interpretation process,” Templeton says, and he notes that ddR is a modality that the department has been wanting to acquire for quite some time. “We first started thinking about it when we decided that we would become an all-digital department,” he says. “We were aware, even then, of ddR’s superior imaging capabilities, and we saw ddR as something that would be very useful in an electronic environment. Now, we have the funding available for it.”

At the moment, the department is relying on computed radiography (CR) machines as its sole means of producing digital radiographs. “We brought in CR first because it was an affordable and flexible way to get into digital radiography,” Templeton says. “We have been using it for portable as well as stationary radiography.” He adds, however, that CR has its limitations, even though it handily surpasses functioning in an analog environment. “With conventional film-based x-radiography, the exposure that you made was the exposure that you were stuck with,” he says. “The only option that you had available for altering that image was bright light, but that only worked if the image was overexposed. If the image was underexposed, you could not really do anything with it. Now that we have the image information captured in a digital format, we can use workstation tools to manipulate that image and adjust it. As a result, there is a lot more that we can do, diagnostically, with each image than was ever previously possible.

He continues, “In terms of the speed of patient throughput, ddR promises to be much, much faster and far more efficient than CR. With CR, one has to deal with imaging plates and with getting those plates processed, and those are time-consuming tasks. Even though CR is digital and its image quality is very good, CR still represents the old model of radiology: the one in which there are many steps involved in work flow. With ddR technology, there are no plates, so you save steps and time right there. The image is simple to acquire and it is available immediately for review and for network distribution.”

While shopping for the right ddR system for the department, Templeton noticed some key advantages that the Swissray product possessed, but that other brands lacked. “The Swissray offering did not use expensive, fragile flat-panel technology, so we knew that it would be a much more dose-efficient and cost-effective piece of equipment,” he says. “It also put forth some very useful features, such as a motorized, programmable, and isocentric C-arm. The flexibility, in terms of patient positioning, that is embodied by that C-arm will bring to us a great deal of improvement in work flow. First, it is a real ordeal for many patients to get on and off of a radiography table and to get properly positioned. In our environment, these patients often come in with complex medical devices attached to them, often as a result of major trauma. Many of them, too, are very elderly and frail, whether because of age or illness. Consequently, we spend a lot of time with each of these patients just getting them on the table and making them comfortable.”

Templeton adds, “With the Swissray ddR, we are not even going to have to put the patient on a table. We can actually have patients positioned standing, if desired. We would stand them between the x-ray source and the detector, quickly take a picture, have the patient turn while still in that standing position, and then quickly take another view. The examination will be over in less than a minute, and we will have avoided all the manipulations that we would normally have to go through. In addition,” he continues, “when the image taking is completed, the technologist will also be able to release the patient immediately and bring in the next one. With CR or analog radiography, the technologist would first have to go over to the processor and would not be able to release the patient until he or she was satisfied that the images turned out correctly. To be able to skip this processing step, alone, is a tremendous throughput and work-flow advantage.”

Forming win-win RELATIONSHIPS

Templeton sought opportunities to develop relationships and partnerships with various imaging companies, Swissray among them. “These relationships were designed to be win-win situations that would enable the university to acquire state-of-the-art technology and allow us to keep moving forward into the future, but do so in a way that was economically viable,” he says. “In return, the university would serve as a proving ground for these companies’ innovative, cutting-edge products. Our staff would use the equipment for research and then write papers on the findings, and our enterprise would serve as a demonstration site at which the companies’ customers could observe the equipment in practical clinical use.”

One such practical use is the TB detection project, which got underway in 1999 when DIANAssociates won a contract to perform TB screening at an INS facility in Port Isabel, Tex. The program grew, in late 2000, with the awarding of a multiyear, multimillion-dollar contract to provide TB screening at additional INS intake centers located in California, Arizona, Texas, Florida, and New York. Soon afterward, Swissray reported receiving, from DIANAssociates, an order for 10 ddR machines.

Leonard J. Benyak, president and cofounder of DIANAssociates, says, “After considering many providers, we chose Swissray because it demonstrated the best image quality, had the best plan for nationwide integration, and provided the closest match for our contractual networking requirements. Their extensive experience in providing clinically proven ddR solutions was also a decisive factor.” John S. Bremer, DIANAssociates CEO and cofounder, says “We provide turnkey patient-to-result health care rapidly and more cost effectively than traditional methodologies, with little or no growth in our client’s infrastructure. For high-impact, profiled programs, Swissray became the logical choice to meet our needs.”

DIANAssociates also chose WAM!NET as the network provider. Under their agreement, WAM!NET hosts and manages, within its data-center environment, the medical records of the screened immigrants. These were previously kept by the US Public Health Service at that agency’s Park Lawn Facility near Washington, DC. Because the TB detection program is provided as a government service, WAM!NET must maintain network-access connections for the DC-headquartered Division of Immigration Health Services, which is attached to the Health Resources and Services Administration (the INS is an agency of the Department of Justice).

Mark Hunter, WAM!NET global health care general manager, says, “The images that are sent across the network are each about 10MB in size. By law, we are required to store these images for 3 years.” The images are stored in a secure, remote archive that WAM!NET calls WAM!BASE. Hunter explains that the images can be accessed at any time via WAM!NET’s managed network or on the Internet. Bremer says, “WAM!NET provides us with a turnkey networking and storage service that allows DIANAssociates-and, ultimately, the INS-to be more efficient in the way that patients are screened. With the ability to send and receive images and to archive them in a centralized database, we are able to manage the multiple INS sites efficiently. Collaboration between the examining physicians at each INS location and University of Maryland radiologists is greatly improved.”

Along with the network and storage services, WAM!NET is providing a clinical reporting system that integrates patient records with the diagnostic images. This is something new, and WAM!NET developed it. “The clinical reporting system allows demographic information to be included with the medical images that are transmitted across the WAM!NET network and stored in our WAM!BASE archive,” Hunter says. “This eliminates traditional, time-consuming, manual paper processes associated with the management of patient records and images.”


On the receiving end, Templeton says, there have been no challenges involved in getting the images into the workstation. “It is all a totally transparent and seamless operation,” he says. “Seated in front of their workstations, our radiologists pull up images from the work list and manipulate them as necessary in order to obtain the views that they need to make a diagnosis. They then produce their electronic reports.” Those reports, returned to the DIANAssociates sites in less than 4 hours, are prepared at the PACS workstation using proprietary technology that returns a report electronically to the sending site. “When significant findings are made, the radiologist also takes the step of picking up the telephone and calling the physician directly at the INS site to relay and discuss his report verbally,” Templeton says.

Ruedi G. Laupper, Swissray chair, president, and CEO, reports that he is gratified to see the performance capabilities of ddR so efficiently deployed in this project. He says, “ddR-based radiographic imaging can solve long-standing clinical, economic, and service challenges for health care providers. DIANAssociates is showing, by example, how readily these benefits can be achieved with a complete system solution.” Including the DIANAssociates installations, Swissray, to date, has taken orders for nearly 120 multifunctional ddR systems since receiving US Food and Drug Administration clearance for the product in 1998, according to Laupper.

Rich Smith is a contributing writer for Decisions in Axis Imaging News.