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November 8, 2004

Going Filmless—Eventually Handling Film Libraries When Converting to PACS
By Kate Jackson
Radiology Today
Vol. 5 No. 23 Page 18

There’s more than one way to handle this important task. Here’s how several facilities did it.

When a facility implements PACS, staff members long for the day when the facility will be truly filmless and the film library obsolete. No more processing and hanging films, no worrying about scraps of paper in film jackets, no chasing down physicians to find films. But getting to this filmless state proves easier said than done. When converting to PACS, how does a facility deal with the existing film library?

Should it move as quickly as possible to the all-digital world by scanning all previous films? Do you scan prior exams only as needed? Or do you scan nothing at all and view priors on film, allowing your normal film disposal schedule to eliminate the film library? While many facilities begin with an ambitious program to quickly obliterate the film library by digitizing everything in it, experience has often shown that effort to be both unnecessary and exceedingly costly.

Thibodaux Regional Medical Center in Louisiana entered the PACS arena in 2002, going live with NovaPACS for CT, MRI, ultrasound, and nuclear medicine. General radiography followed approximately half a year later. Through networking and site visits, Imaging Director Camile Richard, RT(R), learned that many facilities were digitizing their entire file rooms. In the beginning, the hospital paid a hefty price for two film digitizers with the intention of digitizing all returning patients’ prior exams and eventually becoming filmless. That strategy, he says, didn’t last long once it became clear how labor- and cost-intensive it would be to achieve that goal. “We do between 60,000 and 65,000 exams a year at Thibodaux Regional, and it would have taken at least two full-time employees daily to digitize the exams,” Richard explains. Digitizing everything would have eliminated film sooner, but at too high a price.

Thibodaux’s management is not alone in its conclusion. “It’s elegant to think that you’re going to take and digitize all of your backfile or your library and have that online and ready to access, but when you finally start doing it, you realize it’s difficult and it’s just not cost-effective,” explains Jeff Markin, general manager of Eastman Kodak Company’s healthcare information systems division. Many facilities learned this lesson the hard way and now have expensive equipment—not to mention file room personnel—sitting idle. “Scanning everything is very labor-intensive, and it can be very expensive as well,” observes Kay Jex, vice president of sales at NovaRad, a PACS vendor. Jex bluntly sums up the prevailing view: “Most people planned on it, tried it, and then thought, ‘This is ridiculous.’”

Most facilities have scaled down their ambitious goals of scanning entire film libraries or even scanning all relevant priors, revising their plans to make better use of space, personnel, and equipment. “Some facilities just digitize films that patients bring in—for example, those that come from another hospital with a set of films,” says Jex. Others digitize only relevant priors, while others merely pull relevant priors from the film library for physicians to view alongside the current study that’s archived.

According to Jex, radiologists don’t do a lot of comparison studies, so the least expensive way to handle the film library is to let them view priors on their view boxes and dispose of films essentially through attrition—eliminating them after seven years, or whatever is called for by state law. Jex also believes it’s the best and least labor-intensive approach.

Selective Digitizing
At Thibodaux, however, management decided to have clerical staff digitize old films that are requested by referring physicians or those requested for legal cases, and most of those are printed on CDs. The facility itself operates as if it were filmless. All new exams are available for customers throughout the facility and for physicians’ offices via the Web. Exam results and requests for exams are scanned into the hospital’s health information system (HIS). A paper copy is also placed in the empty film jacket—an interim step the facility plans to drop once its radiologists are accustomed to reading them online in the HIS.

In addition, all current consent forms for contrast injection, as well as preprocedure histories, are scanned into PACS. Although the facility itself is filmless, many referring physicians still prefer film, so Thibodaux continues to print film for those who request it. Says Richard, “Our film files—which are stored mainly in the hospital warehouse—are slowly decreasing as we purge and dispose of films of patients who have not had repeat exams in five years.” After it gathers five years of data in PACS, Thibodaux plans to dispose of all film on file.

Less Is More
Pocahontas Community Hospital is a small rural Iowa facility where space is always an issue, says CEO James Roetman. Installing PACS was seen as an opportunity to ease that burden by reducing the amount of real estate needed to store film. Upon implementing its NovaRad PACS, Pocahontas decided to put into the PACS system all its specialty imaging, such as CT, MRI, ultrasound, and bone density scans. Hard copies of those studies are no longer provided unless they are specifically requested. “We were running out of storage space and trying to decide what films to keep and what to put on the PACS,” says Roetman. “Most patients that we see here are return patients, so there would be quite a few films that we would have had to scan, so we chose not to back-digitize at all.”

Because general radiography had not gone to PACS and film viewers were still necessary, Pocahontas opted to simply pull and manually view prior films as needed. Although the state of Iowa requires that films be maintained for only five years, Pocahontas waits seven years to purge films, and by doing so, over time it is significantly decreasing its storage space needs. At the present time, associated paperwork is not scanned, so hard copies are placed in the patients’ jackets. But the hospital will soon link its PACS to a hospitalwide information system so physicians will be able to view electronic reports at the same time as they view images on PACS.

When Mercy Medical Center in Des Moines, Iowa, implemented PACS, it purchased a digitizer and placed clinical view stations on every patient care unit, except for mother-baby and labor and delivery areas (where high utilization wasn’t anticipated). It also put a station in the physicians’ lounge. Susan Johnson, BS, RT(CV), Mercy’s operations director/PACS administrator, wrestled with the issue of digitizing priors from the beginning of the PACS process. Johnson researched extensively, contacted PACS users at many other facilities, and learned about the difficulties from those that opted to scan all prior films.

Fast Film Delivery
What she found was that by aggressively scanning everything, facilities chewed up an enormous amount of staff time, complained about an increased error rate, and that radiologists—often unhappy with the resolution of scanned images—frequently insisted on having film. “We went to our radiologists and sold them on the idea of not digitizing film,” she says. Now, unless a radiologist brings in a film and requests that it be digitized, no films are scanned. If a physician needs to see a prior, Johnson’s staff has promised that the film will be delivered from the off-site storage area several miles away within one hour. “We realized it was a stringent time frame for us to meet,” Johnson says, “but we felt that if we made this effort, we could prove to the radiologists that they wouldn’t need digitized images of priors.” They reluctantly went along, she says.

Once Mercy Medical Center went live with its PACS, says Johnson, her department would run a schedule of patients on the RIS, which would trigger a printer in the film warehouse to print a “film pull slip,” alerting the warehouse staff to pull and deliver the appropriate jackets. Mercy Medical staged going live over a six-month period, beginning with CT, followed by MRI, nuclear imaging, and, finally, general radiology. At first, the priors were delivered from storage as agreed upon, but the physicians quickly balked. Not because the films didn’t arrive quickly enough, but simply because they proved unnecessary. “The doctors started telling us to stop delivering the film because they weren’t looking at it and it was cluttering up their work spaces,” Johnson says. Now, virtually the only films that are taken by courier back and forth are mammography because Mercy Medical is not yet live on mammography PACS.

“Prefetching” Priors
“We quickly found that most of our patients were returning,” says Johnson. “If they’d been here in the last year, we usually had priors on them already in PACS.” Aware that the doctors would probably want to view the exams on plain film to get better resolution, Mercy Medical put viewing boxes in all its PACS viewing station areas and went out of its way, says Johnson, to make the film retrieval system user-friendly. “We knew if we stumbled and fell and didn’t make the process streamlined, the physicians would make us digitize,” she says. The system having been live for more than two years now, most pertinent priors are already archived in the PACS. Mercy Medical has a “prefetching” rule within its PACS that, for example, automatically fetches two priors from the deep archives and pulls them onto a local server so a physician can view them along with the current study. Says Johnson, “There’s no pulling films out of jackets and hanging them on a light box. It automatically happens, and the physicians love it.”

Mercy Medical Center keeps plain films for six years for adults and until the age of majority for minors, and mammography films for 10 years, as required by Iowa law. The storage facility has a numeric filing system, and a report can be culled from the RIS indicating which films can be pulled and discarded, so the hospital is steadily working to whittle down its film library. As the need for film storage and retrieval dwindles, the film library staff is shrinking through attrition. Two years after going live, the staff has diminished by one-half—a significant savings. The hospital aims to move to digital mammography in the next few years, allowing it to eventually even further minimize film.

The hospital, says Johnson, has a football field-size warehouse filled with film. Warehouse storage, she explains, is very costly because film demands climate control. The storage area must be air conditioned in the summer and heated in the winter. The facility must be staffed and couriers must be employed to shuttle film to the physicians and back to storage. It became obvious that so much usable space and expense couldn’t be devoted to film storage, so Johnson’s proposition turned out to be been a winning solution for everyone. The key, she says, was constant communication with the radiologists and a commitment to changing procedures and workflow as necessary to satisfy all involved.

Radiologist Buy-In
When Sutter Gould Medical Foundation prepared to go live with PACS using GE Centricity, the radiologists decided how priors would be handled by sitting down and thinking it through body part by body part, explains Roberta Edge, CRA, RT(R)(M), director of imaging. For example, they decided that when a patient comes in for a chest x-ray, the radiologists would like to see the two most recent chest x-rays. Film library personnel is notified when a patient is scheduled for the x-ray so they can pull the old films, digitize them, and make them available to the radiologists. The same method is used for CT, MRI, and ultrasound.

At Sutter Gould, the digitizing is performed by the film librarians who, having worked with radiologists so long and having gained expertise in hanging film, were seen as ideal candidates. “You can’t just take a stack of film and throw it in a digitizer,” explains Edge. “It has to go in in a certain way so that it will show up appropriately on the monitor for the doctor. Our thought, therefore, was to save jobs and use the people who already have the skills that we’ve taught them to digitize the exams.”

Sutter Gould is an affiliate of Sutter Health, which offered PACS consulting services to each of its affiliates. “We chose to use the PACS consultant to help with this workflow problem because no one on our team had done a PACS implementation,” says Edge. The consultant examined Sutter Gould’s workflow and performed a readiness assessment. The facility had everything in place to move forward and then spent nearly half a year designing the workflow for the new electronic environment. It was clear that Sutter’s radiologists didn’t want to put a prior film into a light box and view it, then turn around and look at their monitor to see the current study. Says Edge, “They want it in one package, ready to go.”

Sutter Gould chose to move all its film to an off-site warehouse, where it stations two former film hangers to digitize film. “We’ve made an agreement with this warehouse that if we call for a stat film, they have to pull it out of the warehouse and deliver it to those employees within 30 minutes,” Edge says. Sutter rents space in the warehouse to hold the digitizer and house the employees whose job it is to digitize these stat exams as well relevant priors for patients scheduled for appointments in the coming days. In this way, they “prepopulate” the PACS with priors. “If a patient is scheduled for a foot x-ray and had a previous foot x-ray as well as a chest x-ray, mammogram, and a CT scan, for example,” says Edge, “we’re only going to pull the foot x-ray and digitize it because it’s the only study that’s relevant.”

One year from now, she says, if that patient needs a chest x-ray, the staff will then put those prior chest x-rays into the PACS. Because the facility has had an electronic medical records system for roughly three years, most paperwork has also been put into electronic format and is available to physicians as they view images.

Planning Ahead
The film library workflow issue, says Matt Long, Stentor’s vice president of marketing, has been largely underestimated by facilities implementing PACS. It’s very difficult, especially from a radiology perspective, to convert to PACS and suddenly go digital because radiologists rarely read one image or exam, he explains. Rather, they read differentials between current and prior images when possible. Digitizing everything is often impractical, and it’s difficult to decide what really needs to be scanned.

“The whole digitization process has completely failed,” Long says. “In most cases, you’ll see the radiologist reading off monitors and looking at prior films on light boxes, which defeats the purpose.” Furthermore, “if you want to take film out of the equation, you have to do so for all of the physicians that require it—not only in radiology, but the physicians in the ICU, the [emergency department], as well as the orthopedic surgeons and neurosurgeons.” The typical PACS process, he says, involves putting in an archive, diagnostic workstations in radiology, and perhaps a Web server for digital distribution of images outside of radiology. “But because you don’t have any digitized films for priors, with this process you’re still having to print and hang prior films,” Long says. That, he suggests, is a stumbling block to acceptance by the nonradiology community.

Radiology Last
Stentor, almost serendipitously, came upon a strategy it believes improves the process. In 2000, the company began to focus on its Web-based image distribution system. Then in mid-2002, it introduced its PACS products. Stentor’s customers appreciated the fact that they didn’t have to worry about the old films in the film library because they already had databases of priors from the Web-based distribution system. “Our customers actually enlightened us to the benefits of this approach, and we realized that it solved a number of problems in deploying PACS. It was a natural fallout of the way we approached the business and entered the marketplace. If you start outside the enterprise first and get the buy-in from the referring physicians, and at the same time build this database of information, the transition of radiology to PACS is very simple and straightforward.”

Stentor advises customers to install a robust Web server or Web-based distribution system first, before even focusing on PACS in radiology. “Start handling the digital distribution of images outside of radiology for from three to six months,” Long advises. “By doing so, it will accomplish two things. First, it increases buy-in from a very vocal and often contentious referring physician community that wants to be filmless, and it helps them build a database of essential priors. Almost all of our PACS customers to date have started with Web distribution and have solved the image distribution problem and have a Web server with six months’ worth of image data on it. So when they go live in radiology, they have a robust database of priors already available to use as comparisons, and the digitization is essentially zero. It’s proven to be very successful because it allows radiology to go filmless overnight.”

One of Stentor’s customers, Providence Health System, in Southern California, focused on Web-based distribution for one year, and when it went live with PACS, it was 80% filmless. The only studies they were printing were mammograms. Providence was effectively filmless in less than four months and shut down its film library. “They didn’t have to digitize films, they didn’t have to worry about joint workstations and light boxes. It solves an awful lot of problems,” says Long.

— Kate Jackson is staff writer for Radiology Today.

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