Kathy Kroupa, RT (left), and G. William Woods, MD, Fondren Orthopedic Group, Houston, Tx.

More people with sports injuries and musculoskeletal problems go to Houston’s Fondren Orthopedic Group, LLP, for treatment than virtually any other private practice in that sprawling metropolitan region. Not surprisingly, then, Fondren Orthopedic Group’s in-office radiology department ranks among the very busiest found in the area. In a typical day, as many as 200 patients have imaging procedures. Until early 2001, those studies were produced with the help of nine full-time equivalent (FTE) technologists operating six analog-film x-ray machines. Now, the department is handling the same examination volume, but with three fewer technologist FTEs and only a single analog unit, a feat attributed to the arrival of a pair of direct digital radiography (ddR) systems. Their addition dramatically improved efficiency and reduced imaging costs almost from the first day after installation.

Kathy Kroupa, RT(R), radiology department supervisor, says, “Patient throughput is way up now. Because the images are generated digitally, there are no films to process, so the waiting time for that step is eliminated. There is almost no waiting for the machine to charge and relax between exposures. You take a picture and, a few seconds later, it shows up on your workstation monitor. Since the system is heavily computerized, it is almost impossible to take a bad radiograph.” She adds, “Even studies that are normally time consuming to do because of the number of images that must be taken and the need to position the patient carefully on the table are completed far more quickly. For example, a seven-view lumbar spine study used to take 15 minutes; now, that same study is done in 5 minutes.”


Kroupa explains that many of the patients come to the department in wheelchairs. Previously, they had to be lifted out of them and maneuvered onto the table. This was sometimes a struggle, and always a time-consuming operation; it is not any more, she says. “Because of the sophistication of the new systems, we can now just roll the patient into the room, park the wheelchair in front of the detector, maneuver the powered C-arm to where we need it to be, and take the picture. Not having to go through the chore of lifting patients out of a chair is a real time saver. There is also a lot less wear and tear on our technologists; they’re not exhausted or stressed out by the end of a the day from heavy lifting.”

The ddR machines are so efficient that one unit alone can easily handle the imaging load of two analog radiography rooms. Prior to the new equipment’s installation, the department deployed one technologist per room. Since some analog radiography rooms were no longer needed, the technologists originally assigned to those rooms were redeployed into the rooms with the ddR systems, thereby pairing personnel. “Working alone, a technologist was so hurried and frazzled that he or she had no ability to do anything more than give cursory attention to the patients,” Kroupa says. “That all changed when the technologists began working two to a room. They were then able to answer patient questions and engage them in conversation. The patients now leave the room feeling better about the experience. That contributes to their overall satisfaction with the quality of care received at Fondren Orthopedic Group, and that is extremely important to us.”

Kroupa adds that the ability to move patients in and out of the radiography room more quickly means that more cases can be scheduled each day. “You peek into our waiting room and you will think that people must be waiting a long time, judging by the fact that there are so many of them sitting there,” she says, “but that is not the case at all. A person who walks in will barely have time to get comfortable after sitting down in the chair before getting called and escorted back to the radiography room.”

The Fondren Orthopedic Group physicians who order the examinations likewise marvel at the speedier service. “The throughput is amazing,” G. William Woods, MD, managing partner of the group, reports. “I can send a patient down the hall for imaging, and the image is in front of me before the patient gets back.”


Fondren Orthopedic Group, founded in 1973, now operates in 16 locations throughout greater Houston. The 41 orthopedic surgeons who belong to the group represent 20 subspecialties, which allows Fondren Orthopedic Group to claim a degree of subspecialization unmatched in the area. “We were the first orthopedic group in Houston to subspecialize,” Woods, whose own focus is sports medicine, says.

Fondren Orthopedic Group also is distinguished in the market by virtue of the orthopedic inpatient surgery hospital that it co-owns with the Hospital Corp of America. The facility, Texas Orthopedic Hospital, is a state-of-the-art institution, and the only one of its kind in Houston. “Our hospital is specially equipped for the needs of orthopedic surgery,” Woods says. “It even has its own MRI and CT imaging capabilities.” Texas Orthopedic Hospital shares a stylish, three-story building with the Fondren Orthopedic Group’s medical and administrative offices. “We are all under one roof,” Woods explains, noting that the ddR-equipped radiology department is in the medical office wing of the building.

Fondren Orthopedic Group, Woods says, had, for quite some time, been looking for replacements for the analog radiography machines in that department. “The equipment had become badly outdated and was at the end of its useful service life,” he says. Kroupa adds that some of them “were so old that parts were becoming hard to obtain. It was at the point where we were practically holding the machines together with tape, glue, and rubber bands.”

As the group considered buying new equipment, decision makers determined that replacement machines ought to be sufficiently advanced so as to contribute to greatly improved productivity, as well as to a reduction in costs. “One of the problems with our traditional, analog radiography machines was that we had to maintain a large amount of physical space to file the voluminous number of films being produced,” Woods says. “In addition, because we were putting out film, a tremendous amount of employee time was being used to search for images that had been misplaced or misfiled. We were spending a small fortune on film stock, processor chemicals, and film jackets: something on the order of $28,000 per month.”

In 1998, ddR emerged as a potential solution when Woods attended a meeting of the American Orthopaedic Society for Sports Medicine. On display in the exhibit hall was a ddR system made by Swissray. “I was immediately impressed by the quality of the images, the ease with which those images were produced, and the sheer speed of operation,” Woods recalls. Other digital radiography suppliers were on hand for that meeting. Woods visited their booths as well, but came away convinced that the Swissray offering was, by far, the best. “The other companies had based their systems on flat-panel detector technology, which is as expensive as it is unreliable,” he says. “Worse, several of the vendors that we talked to did not even have functional systems. They just offered promises. Their presentations were all about the things that they were theoretically capable of achieving. Meanwhile, Swissray was miles ahead of everyone else. They had an actual product and an installed customer base. We decided that Swissray would be the one with which we would do business.”


Kroupa was aghast when she first learned that Fondren Orthopedic Group planned to acquire a pair of ddR systems. “I was set against it,” she says. “I had heard all kinds of horror stories about digital radiography: the machines were vulnerable to constant breakdown, and the operating features were so poorly conceived that they were difficult to use and not very efficient.” Those tales struck Kroupa as true, but only because she was not acquainted with Swissray. Accordingly, a Swissray representative invited her to visit an installed site where she could see a demonstration of the system. By the end of the inspection, Kroupa’s apprehensiveness was gone.

“It was clear that ddR, as put together by Swissray, was excellent technology and would, indeed, work in our facility,” she says. “I looked at this equipment from every angle and thought about every conceivable type of examination scenario to see whether it would be better or worse than what we had been using. In every instance, it was shown to me that it could easily handle the task and would be superior to our old equipment.”

Due to the way that Fondren Orthopedic Group is structured, a decision to commit capital for the acquisition of the ddR systems required a vote by all the physician partners. “Acquisition was not something that could be authorized by an administrator alone,” says Kroupa. “First, the physicians had to be convinced that this was a legitimately worthwhile investment.”

Woods notes that the physicians’ decision to approve the ddR acquisitions hinged on obtaining satisfactory answers to two key questions. “We wanted to know,” he says, “first, was the technology developed enough that it would be reliable, and, second, was the vendor going to provide full service and meet our needs? The answer to both questions turned out the be yes.” There were, of course, other considerations. The physicians wanted to know, for instance, whether the systems could generate the true-to-size images that are important for the planning of implant surgery and whether images could be easily manipulated to reveal details that one type of subspecialist would find more pivotal than another. Again, the answer was yes, Woods reports.

Fondren Orthopedic Group stands as a powerhouse of orthopedics in the Houston market, so the decision to acquire ddR was not motivated by a need to fend off competitors nipping at the group’s heels, Woods reports. “There is only one other group that is close to us in size, but it is not in a position to overtake us.

When the Fondren Orthopedic Group’s physicians voted to allocate the funds to invest in ddR, they authorized acquisition of two systems. The first was installed in March 2001 and the second, 3 months later. Five of the aging analog radiography machines were mothballed. The sixth (the one that was in the best condition of the lot) was kept fully operational for 6 months at the request of a handful of physicians. “Not everyone was immediately comfortable working with images in a digital format,” Woods says. “It took some time to get accustomed to it, so we continued to make analog film images available.” By the end of the 6 months, though, all the physicians were digital system users, and happily so. “We are not doing analog images any more, but we are still keeping that last film radiography machine as a backup unit in case either of the two digital systems goes down,” Kroupa says.

The radiology department placed one ddR system in each room formerly occupied by an analog unit. That left three rooms completely vacant, but not for long. “Fondren Orthopedic Group has grown so much in the past few years that we have become cramped for space throughout the facility,” Kroupa says. “As a result, we turned one of the vacant rooms into a storage area. The other two have been converted into administrative office space for the purchasing department.”


The images produced by the ddR systems are not first read by a radiologist before reaching the surgeons. Rather, they are sent directly to the orthopedist who ordered them. “Texas Orthopedic Hospital has radiologists who are available for consultations, if desired, but the orthopedic surgeons normally make their own interpretations of the ddR images that we send them,” Kroupa says. The images are distributed electronically, she adds. “As soon as we are done taking the exposures, the images are transmitted to the ordering physician’s computer,” Kroupa explains. “The outpatient wing of the building is organized into 11 pods. Each pod has five examination rooms and a nurses’ station. The computer is located at the nurses’ station.”

To access images, the physician simply types in the patient’s clinic number. Woods says, “The image pops up immediately. We can manipulate it, measure it, and enlarge it. It is easy and very efficient. Images are never lost because there are no hard copies to handle.” When images are no longer needed for viewing, the physician clicks a command that routes them to an image-management server. “It is a type of mini picture archiving and communications system,” Kroupa clarifies. “Basically, the images are stored on a digital-versatile-disc based jukebox. Digital radiography is the only modality tied into this image server. Unfortunately, none of the images on it can be transmitted to the inpatient hospital side of the building. If the surgeons want to have images with them in the operating room, they have to be printed off and then hand carried there.”

This will probably change within the coming 5 years, Woods predicts. He says that the group is already thinking about installing a ddR system in the hospital and outfitting the operating rooms with viewing monitors. Woods speculates that convincing his colleagues to authorize acquisition of that additional ddR system will probably be much easier in light of the group’s familiarity with the technology. “It has performed very well for us,” he says, “and has surpassed our expectations.”

It certainly did that with regard to staff time, Kroupa report. “Some of our technologists (mainly those most recently hired) quit their jobs when it was announced that ddR systems were coming,” she says. “They did not do that in protest. They knew that big efficiencies were going to result from this equipment, so they assumed that they would not be needed. Instead of waiting for word about it from the top, they decided to find jobs elsewhere immediately.” Administrators planned on allowing attrition or reassignment (rather than layoffs) to eliminate three technologist FTEs, but five FTEs departed voluntarily. “This left us understaffed,” Kroupa says, “and we really had to scramble until we were able to start building our FTEs back up to an appropriate level. I’m convinced that if we had not had the Swissray ddR systems, we would have experienced serious backlog problems.”

Many of the Fondren Orthopedic Group satellite offices are equipped with analog radiography machines. Woods says that he would personally like to see those units give way to digital systems, but he knows that this probably is not practical yet. “The satellites mostly have just one or two physicians at them,” he says. “Their imaging utilization is not sufficiently high to justify the cost of digital imaging in their offices.” Kroupa, however, can think of ways that it might be possible for them to become digital. One would be for at least the largest satellites to acquire Swissray’s ddR Combi unit, which is a smaller, manual version of the system in the Fondren Orthopedic Group’s main office. Another would be to establish three or four stand-alone imaging centers, each dedicated to serving the digital radiography needs of the four or five nearest satellite offices.

“Whichever way we decide to go, one thing is clear: ddR works,” she says. “Everyone loves it: the physicians, the patients, and, most of all, the technologists. We still cannot believe how quickly it makes things happen around here now.”

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