What comes to mind when you read the word “efficiency”?
Well, if this were Motion magazine, you would expect to read about the effect of load on “efficiency” — a factor to consider when replacing motors.
And if this were European Car magazine, you would look forward to a panel of automotive designers rating a car’s aerodynamic “efficiency.”
And if this were any one of numerous decorating magazines, you could find yourself flipping through a photo essay illustrating all the charming nooks and crannies in a sunny “efficiency” apartment (in a historic building. They are always in historic buildings).
But this is Medical Imaging. So when Felipe Patino and Denise Wagnon trumpet “efficiency,” you can trust that they are not talking motors, measurements or accommodations but rather, proclaiming their No. 1 reason for installing digital radiography (DR).
“We considered digital for efficiency,” begins Denise Wagnon, principle radiologic technologist at the outpatient clinic located on the campus of the University of California San Francisco (UCSF), “And part of that is our Powers-That-Be were aware that digital was coming. There has been digital with CT and MR for years and it was time for general radiography to catch up.” Wagnon also assumes floor supervisory responsibilities for the clinic during its five-day-a-week, 8:30 a.m. to 5 p.m. operating hours.
Wagnon remembers the clinic’s first brush with digital — a Canon unit, about three years ago, that participated in a study comparing film-screen and digital capabilities. Imaging and image manipulation went well, but system operation proved labor intensive. (That’s since been fixed as well.)
Eighteen months later — which neatly translates to 18 months ago — the clinic came into possession of a Revolution QX/i prototype from GEMS. And oh! What a difference three years makes! “It’s very user-friendly, and it makes a world of difference in our patient care,” she says.
Much like any other outpatient clinic in a campus setting, the UCSF clinic cannot control its own scheduling so as to pace patient traffic throughout the day. That’s because its patients hail from a number of medical practices on campus, particularly the orthopedic, cardiology, hematology and oncology groups. Currently, the Revolution QX/i performs approximately 6,500 chest studies a year and ties into the university’s RIS (radiology information system) and its Agfa Health Care (Ridgefield, N.J.) PACS. Twelve technologists handle all imaging, and one radiologist is on the premises most of the day — or within paging distance if at one of the university’s seven radiology departments.
DR has helped “handle the day,” according to Wagnon, enabling the clinic to increase patient throughput, nearly eliminate patient demographic errors, cut its repeat rate and reduce film costs. In other words, DR has helped the clinic operate more efficiently.
“With our film system, a chest X-ray took one technologist 15 minutes to do, and now you’re talking about one technologist getting a chest X-ray done and a patient out — leaving the clinic — in two minutes. It’s a huge accomplishment,” she observes. “You can now have a technologist pick up requisitions on six, eight, even 12 patients and have them out, walking out the department, within a half-hour or so. That has been one of the biggest differences.”
“Also, the exposures have been identified already, they are ‘developed’ — the technologist knows the patient is finished because she has the images in front of her — and she knows they are being sent to the radiologist, so there is even less follow-up afterward,” she goes on. “Was that film marked correctly? Did it have the name on it? You don’t have to worry about that anymore. I think I.D. errors have dropped to just about nil, because the exams come with a bar code on the request when they are registered, and once they are bar-coded, that has to be the right name.”
Clinic accounting doesn’t fall under Wagnon’s purview, so she can’t quote dollars and cents saved due to the DR installation. But she doesn’t need to see the numbers to know that DR has meant a reduction in film and associated costs.
The clinic continues to print some film for the university’s hematology and oncology groups, and it prints every image ordered by the university’s orthopedic physicians. Studies done for the general medicine departments or those that stay in the outpatient clinic are all soft-read.
“We print only about a fourth of the films we used to — that’s a dramatic drop,” she remarks. “We closed down one processor completely; we have only one running because we need it so seldom. We used to order cases of film in different sizes and with different cassettes. Now we just have the one-size laser printer, and we don’t use that nearly as much as we used to. So the film expense has dropped. And if it wasn’t for the orthopedic demand, we would hardly print anything at all.”
DR’s helping to “handle the day” also means the clinic has been able to manage an increase in patient population without adding technologists to the staff.
During preparations several years ago for a merger between UCSF and Stanford University (Stanford, Calif.), the clinic lost a technologist. When that merger failed, the position remained vacant.
“We didn’t get the original technologist back, and, as our patient load increased, we probably could have used that one — plus another,” Wagnon calculates. “But we would not be able to do what we are doing now with one less technologist if it wasn’t for the DR system. That’s made us able to function as we are, with that loss already in the picture.”
Southerly DR
If one DR installation promotes efficiency effectively, two can only double the savings — right?
Houston (pronounced House-ton) Healthcare Complex (Warner Robins, Ga.) reaped such good results with its first Swissray International Inc. (New York) ddRCombi Automatic system at its Houston Medical Center that Director of Radiology Services Felipe Patino purchased a twin system for the organization’s Perry Hospital 17 miles down the road. Houston, a 200-bed hospital, has had DR its emergency room (ER) since December 2000; Perry, with 60 beds, installed DR in its ER in June. A third facility, the Houston Health Pavilion imaging center, completes the complex.
The complex also purchased Agfa Solo and Compact CR units at about the same time. All DR and CR integrate with a Meditech Corp. (Westwood, Mass.) RIS/HIS (hospital information system) and will feed into a MarkCare PACS from EMC Corp. (Hopkinton, Mass.) in the implementation stages. A Web browser product from EMC is in the works.
Houston Medical performs 27,500 general radiography exams a year, 60 percent of which originate in the ER. Perry logs 15,000 general radiography studies a year.
When he went looking for DR, Patino held fast to several criteria: He wanted efficiency.
“Our best turnaround time [from ER-to radiology-back to ER with radiologist report in hand] was 45 minutes because it’s a couple of hundred yards from the ER to the main [radiology] department,” he explains. “ER had set some benchmarks for us because they had delays in the bigger picture of getting patients in and out of the ER. They wanted us to get down within 30 minutes of turnaround time.”
He wanted durability.
“I looked at the Hologic flat-panel technology and didn’t think it was durable enough. I needed something the techs couldn’t destroy,” he says. “Having been a tech for over 23 years, I know that technologists sometimes don’t take care of the equipment as much as you would like them to, especially in a very busy ER setting —and we do quite a bit of trauma here. Just because of the speed and the conditions you have to work under, you have to have something durable.”
He wanted a proven technology.
“CCD [charged-couple device] has been around for a long time. The others are good systems, they had good quality, but I needed something that would work now, something that had been proven.”
He wanted service too.
“Swissray wasn’t well known at the time, but I knew they were affiliated with Hitachi Medical Systems America Inc. (Twinsburg, Ohio), which is very good for service. I had good references from my peers and had someone in the local area to call right away. Swissray set someone up here with Hitachi locally. They can service both our units.”
Nearly a year after the ddRCombi came to Houston Medical, Patino reports that radiology services not only met — but also exceeded — its time efficiency goal.
“Our goal was to do 30 percent of patients in 30 minutes, and we achieved [imaging] 99 percent of our patients in 30 minutes turnaround time. Now the ER complains that we’re too quick and cause triage problems!” he exclaims.
Patino declines to disclose purchase prices, but he offers this partial list of considerations that went into making his argument for DR.
• Film and storage costs: calculating the annual cost of the file room, the storage area and the number of buildings that housed the archive, then contrasting that with the square footage used for archiving once the PACS was up and running.
• Utility costs for those areas.
• Purging film costs: the cost of either bringing in a company to digitize prior studies or paying overtime to employees to do the work. Patino notes that physicians were particularly helpful; they agreed that only three or four pertinent studies need be digitized. Other, older studies were allowed to age out through attrition, which is what generally happened with film every five years.
• Supply costs: film jackets, labels, chemicals and more.
• Film transport costs: Many of the county’s 118,000 residents avail themselves of the services at Houston Healthcare’s three facilities. DR and PACS eliminates the cost of someone driving films from one building to another for reading and historical interpretation.
• Postage costs for film mailing.
• Flexibility in staffing: Patino plans to use new hires with computer skills as “tech aid assistants.” In place of two technologists moving patients in and out of the ER, one technologist will image the patient while an assistant manipulates the images, evaluates them as part of the quality control process and sends them to the PACS.
“On the average, we used $32,000 a month on chemistry and film previous to DR,” Patino reveals. “I don’t have the data for the last month when we’ve not printed — we changed our printing system to the DryView laser so in the last few months costs that were associated with analog film printing were transferred to DryView printing and were a wash — but when the data comes in from that last month, I will be able to say, ‘This is how much we have been able to save by not using this dry printer.’”
Initially, radiology services printed film as part of helping physicians feel comfortable with images moving across the PACS, not because of anything to do with digital capture, says Patino. And while he suspects that a 100 percent filmless environment is unrealistic, he also intends to get as close to filmless as is operationally possible. “Progressive radiologists” are helping make that happen — but their enthusiasm comes at a price, he suggests humorously.
“The average age of our radiologists is 35. They’ve all had training at places like Harvard, Stanford, University of Maryland, and all have been exposed to a digital, filmless environment. But there are counter-benefits to that as well. Because they are all progressive, radiologists always look at areas for improvement in how software comes to them, and they have their own interpretation of what would be the ideal system. So from an administrator’s perspective or a radiology director’s perspective, you bought what you thought was the best software out there, but as they review it they say, ‘If they can get picture-in-picture features, if they can do it for a TV set, why can’t they do it for this so I can watch the news at the same time I’m doing my work?’
