Henry Ford Hospital utilized Kodak’s DR 7100 system.

An increasing number of healthcare facilities today are taking the plunge into the digital radiography (DR) waters, keeping close watch on the tide of costs and benefits.

While the initial investment in DR can consume a fair amount of a healthcare facility’s capital budget in any one year, the promise of cost savings, improved efficiencies and enhanced patient care often buoy the argument in favor of obtaining the new technology.

The decision to transition toward a filmless environment is just the start of what can be an arduous process to convert from long-standing traditional technologies and into the 21st century.

Holy Name Hospital as told by Vito Comes, administrative director of radiology
When it comes to the x-ray department, the digital revolution has stopped dead in its tracks at many small community hospitals and independent practices, due in large part to high technology costs and limited budgets. While many practices stand to gain plenty in conversion, the payback in economics, productivity and other benefits presents a rather different picture than at large hospitals. Understanding this is essential to a digital conversion that successfully meets expectations.

The 365-bed Holy Name Hospital (Teaneck, N.J.) ushered in digital acquisition with a one-room digital radiography (DR) conversion in 2001, according to Vito Comes, administrative director of radiology. As part of the project, the facility looked at numerous options, including computed radiography (CR), complete new DR suites and DR retrofits. Eventually, Holy Name selected to go the retrofit route. We felt we were extremely circumspect in our decisions, and in many respects our choices were right on target. We did experience some surprises — both good and bad — and are marching forward with eyes wide open in our plan to convert to full digital acquisition over the next few years. In many ways a fairly typical suburban hospital, Holy Name and the story of its digital conversion can help others navigate the potential and pitfalls of digital conversion on a small scale.

We got our feet wet in digital technology four years ago with installation of an extensive picture archiving communications system (PACS). The PACS managed all inherently digital modalities from MRI and ultrasound to nuclear medicine. With archived images immediately entered into our new system, full digital workflow was well received in the department and throughout the hospital, with productivity gains of between 20 and 40 percent depending on the modality. The next logical step was to bring x-ray — which consists of five radiographic and two fluoroscopic rooms — into the digital system. Naturally, this initiative was a far more complex and costly proposition.

Unlike many hospitals that have transitioned to digital imaging, Holy Name went directly to flat-panel DR acquisition without implementing CR. Boosting a technologist’s efficiency, we surmised, would lead to greater customer satisfaction. Cutting departmental costs, as is often the case, was not the principal reason for our choice. For the facility, the numerous benefits of moving x-ray to PACS were already clear. We knew from the start that a community hospital, such as ours, did not have the critical mass of cases for the productivity gains that may be realized by larger hospitals.

As administrative director in 2000, I headed up the project, reviewing specifications and ultimately recommending a vendor. The budget was limited and certainly not sufficient to convert all of our rooms. It also did not include the technology necessary to convert a large portable exam volume to digital. Making decisions based on our financial allowances was a major challenge.

Priorities, trade-offs
Like most hospitals with limited funds, Holy Name made trade-offs in conversion, but accomplished what was most important — a seamlessly tie DR into the facility’s PACS, taking us another step closer toward a complete filmless environment. A particular benefit of filmless was the elimination of lost films, which is a significant issue for any hospital and we wanted to create a generally positive experience for all involved in this initial conversion to ensure their support.

When Holy Name purchased DR two years ago, retrofitting our existing rooms became the most viable DR option. Although, during the past two years manufacturers have expanded their offerings and far more options now exist.

For us, CR also was particularly appropriate, because tech utilization rate was between 70 to 80 percent. DR would make our techs more efficient, but often with no additional patients waiting in the wings, we would not be handling more cases to realize the added revenue predicted by many economic justification models. In the end, we went with DR because management was committed to buying cutting-edge technology they felt would not become outmoded. We bought a dual-bucky flat panel DR retrofit for a single room.

Edge Medical displayed its workstation and software for its digital radiography system at the 2002 annual meeting of the Radiological Society for North America (RSNA).

If the digital transition is in part a waiting game as technologies progress and costs come down, then keeping an eye on emerging technologies can be another important tactic. For example, Edge Medical (Hackensack, N.J.) is developing a technology designed to reduce the cost of compact high-performance flat-panel DR detectors and produce high-quality medical images. With a clinical beta site operating since early this year, Edge’s Scanned Matrix Array Readout Technology (SMART) could reach the healthcare market by early next year, offering low-cost flat-panel DR upgrades. Edge anticipates that its DR upgrade will sell in the range of CR technology and eliminate the need to compromise workflow performance and necessary features for cost. Edge Medical expects the technology to be available in retrofit as single and dual receptor configurations and new room options as well.

Technology transition
Holy Name also plans to reduce costs by using single-detector DR rooms. Following the conversion, the dual-bucky receptor configuration proved extremely useful in maintaining the facility’s throughput. Now that the technical staff has acclimated to digital, we feel more confident that a dual-receptor system may not be absolutely necessary in many cases. Although Holy Name did purchase another digital room with dual-detector configuration for the emergency room, the facility also moved one detector from our initial DR room into another room. The configuration gives Holy Name two rooms with single detector configurations. With sufficient training, we felt our technologists would be able to do most studies utilizing the single receptor systems. It gives us two digital rooms for a fraction of the cost. If money were no object, the dual-receptor system would be the configuration of choice.

DR’s versatility
In general, we were pleasantly surprised by the ease and versatility of DR. Even patellar views, which we thought would be difficult, proved to be easier than we expected. With an open mind and a little practice, our technologists easily acclimated to the technology. Unfortunately, stretcher work and some cross-table work are difficult if not impossible to perform with conventional DR configurations.

One transition, however, that is never easy is comparing old hard-copy studies to new digital images. Most radiologists find this extremely awkward and difficult. Naturally, this problem will diminish with time. We chose not to go the scanning route to convert existing films to digital for various reasons but you might consider it. Also we have found that many of the referring physicians have a difficult time not having a piece of film in their hand. While there are always those — doctors, technologists, administrative staff alike — who do not like changes of any kind, the overwhelming majority of professionals involved were extremely happy with the move to digital.

Our current plan is to move as quickly as possible towards full digital acquisition with a combination of DR and CR. Perhaps the most dramatic testimony to the success of our new digital department is that most providers are looking forward to the day when we are 100 percent digital and the only complaints we hear are when doctors have to go back and pull films.

Henry Ford Hospital as told by Michael J. Flynn, Ph.D., radiologic physicist and Marnix van Holsbeeck, M.D., radiologist and director of muscular-skeletal radiology
Henry Ford Hospital (Detroit) is a 903-bed primary tertiary facility, which installed a DirectView DR 7100 system from Eastman Kodak Co.’s (Rochester, N.Y.) Health Imaging division in August 2002. Henry Ford served as a trial site for the DR 7100 for both inpatient and outpatient imaging general radiography procedures.

Michael J. Flynn, Ph.D., a radiologic physicist at Henry Ford, led the team that evaluated the DR 7100’s performance, while Marnix van Holsbeeck, M.D., radiologist and director of muscular-skeletal radiology at the facility has been involved actively in the DR 7100’s use and evaluation.

Most of the procedures performed on the DR 7100 relate to oncology and metastatic surveys, as well as work-ups of myeloma patients, which typically is quite involved in the number of images taken. In a number of cases — especially the skeletal surveys — van Holsbeeck says facility radiologists have been able to compare the digital images with prior computed radiography or films that were done with conventional techniques. The comparisons show — in his words — “big differences,” especially when imaging the skull, the cervical-thoracic region and the diaphragmatic area.

“In terms of image detail, we see anatomy that we know is there, but it is rarely displayed, like the socket of the teeth, which can be very useful, if one is looking for metabolic bone disease or osteoporosis,” adds van Holsbeeck. “If you don’t see it on the conventional radiograph or by computed radiography, you don’t know if it is not there or if it is eroded. Sometimes you have a lucky shot and you see it. Now we’re consistently can tell if it is there or not.” Henry Ford’s general radiography unit averages some patients per day. While the facility has not conducted a study to detail the time savings that have resulted from use of the DR technology, van Holsbeeck says throughput has improved, in part because there is no need to handle film cassettes. A benefit, he says, especially for imaging procedures that are as involved as skeletal surveys.

“From a technical standpoint, we have a sense that the exemplary performance of the selenium direct radiography panel is in areas where high detail is important,” says van Holsbeeck. “That’s why we have had a focus on the muscular-skeletal work” using the DR 7100. In December 2002, Henry Ford did examine the number of steps a radiologist would take to complete an imaging procedure, comparing DR, CR and screen film. The conclusion was that the number of steps required for a DR study were “notably reduced,” says Flynn.

“While [DR] does perhaps cost more,” he adds, “there is a benefit in productivity.” Henry Ford also has the benefit of a full enterprise-wide picture archiving and communications system (PACS). The facility’s medical imaging modalities begin the patient information process with a work list query, as patients are registered to the radiology information system (RIS). The examinations then are conducted with the patient demographics verified on a display monitor and sent to the PACS. As for future applications of the DR 7100, van Holsbeeck says the system may be utilized for metabolic work-up, oncology, and trauma in the emergency room.

“We have been struggling somewhat with some of the high detail that we used to have in hand films,” he adds. “This [DR system] seems to be a step up from that, because we have the high detail of the bone and we have the high detail of soft tissue which we didn’t have before.”

Flynn notes the facility also has been pleased with the user console and graphic interface. The DR 7100 has provisions to load all medical imaging procedures and define the particular views that are required for those procedures.

“For those views,” Flynn adds, “it allows small, postage-stamp type images that illustrate the positions associated with those views.” The feature provides what Flynn describes as a “picture book of anatomic positioning” for student technologists from which they can see and learn.