July 13, 2009

Implementing Digital Radiography
By Dan Harvey
Radiology Today
Vol. 10 No. 13 P. 12

Aaron Ybarra maintains a broad perspective about digital radiography conversion, thanks in large part to his time spent as a radiologic technologist. Later, as a vendor representative with an extensive sales background, he witnessed up close how implementation impacts radiology departments.

In particular, he observed how digital technology can reduce the number of x-ray rooms needed. “If a facility’s radiology department has five x-ray rooms, it doesn’t need to purchase five digital systems,” says Ybarra, now the product manager for x-ray and fluoroscopy equipment for Toshiba America Medical Systems. “One client felt it needed to install five systems to match its number of x-ray rooms,” he recalls. “But when I later checked in with them, I noticed that their volumes were up, but that most of their rooms appeared empty.”

When questioned about this, the client revealed that it could service patients so fast that only three rooms with direct digital radiography (DDR) systems were truly necessary.
“Increased efficiency made the other rooms superfluous,” explains Ybarra. “Subsequently, I make sure our sales staff realize the implications of the increased productivity.”

This anecdote underscores how DDR’s impact can simultaneously be explosive and implosive. It’s explosive in the sense that the technology cuts costs, saves time, improves patient care, and enhances radiology department efficiency via improved workflow. At the same time, DDR’s impact is implosive because the efficient technology enables facilities to reduce the number of x-ray rooms. Facilities also don’t have to substantially reconfigure existing room layouts to implement the technology. “No one ever had to raise a ceiling or break out a wall to install a digital radiography system,” Ybarra says.

Digital technology can be easily incorporated and provides significant benefits, according to Thomas M. Boon, president and CEO of Imaging Dynamics Company Ltd. “Implementation entails minimal room change,” he says. “If existing equipment is relatively new—that is, five to seven years old—then digital technology, whether it’s CR (computed radiography) or direct digital, is easily incorporated and provides similar but improved functionality.”

Most vendors don’t want customers to modify room configuration. “We prefer that their rooms remain pretty much the same as before conversion,” says Tom Treusdell, director of radiology and fluoroscopy for Siemens Healthcare. “This approach enables technologists to experience the same easy interaction with equipment.”

That’s why the in-room hardware remains basically unchanged, notes Ybarra. “You’ll still see a table, wall stand, and overhead x-ray tube,” he says. “However, additional room does have to be made for a console. Previous x-ray rooms had a touch-screen generator that was mounted on the wall or placed on a pedestal. With digital x-ray, the console integrates a generator, patient entry, postprocessing, and sends images to PACS to provide a single point of contact. Still, it doesn’t require a lot more room.”

All of this indicates why only reasonable modifications are necessary to maximize technologist productivity and boost patient comfort, says Penny Maier, director of imaging systems for FUJIFILM Medical Systems USA, Inc. “Previously, rooms were set up near a central film processor or multiplate CR reader,” she says. Now, compact digital x-ray systems can fit right into the room and distribute workflow in a way that makes it easy for the technologists to access controls, stay with the patient, and review images quickly, all while minimizing patient waiting times.

Increased Flexibility
Many facilities seeking to convert to DDR seek a lower end, lower cost system, which has driven the application of U-arm technology. Originally designed for chest x-rays, the technology is comprised of a post that supports the x-ray tube and detector. As it pivots around the patient, it allows the user to perform a variety of exams. “U-arm configuration eliminates the need for floor-mounted and overhead tube cranes for most outpatient centers, orthopedic groups, and multispecialty groups,” says Bruce Ashby, general manager of Viztek.

Recently developed positioning systems provide better equipment utilization with more capability for broader exam types. “For example, in orthopedics, users can accomplish cross-table work with a single detector, as well as weight-bearing exams, which are difficult to do with existing rooms,” says Boon.

Also notable is the transition from fixed to wired to wireless detectors, says Treusdell. “Wireless detectors allow more flexibility within the procedure room and aren’t integrated within a hospital’s network,” he points out.

Fewer Rooms
All of this leads back to the room issue. Because of digital speed and flexibility, fewer rooms are needed to handle increased patient volumes. With digital technology, image processing has decreased from the 90 seconds required with conventional film radiography to less than 20 seconds with CR and then to less than seven seconds with DDR, in most cases. “For instance, Fujifilm’s DR systems can paint the first image within two seconds, allowing technologists to quickly confirm proper positioning and then begin the next view,” Maier says. “Since most examinations consist of three images, speed is quite beneficial and increases patient turnaround.”

With the enhanced productivity, facilities only need one half as many rooms, according to Scott Burkhart, vice president of general x-ray and surgery for Philips Healthcare. “When we introduced our Digital Diagnost in the United States at Dartmouth, they went down from 15 to 18 minutes per patient exam time to one to three minutes,” he reports. “With that kind of reduction, they didn’t need as many rooms because the patient won’t occupy x-ray machine space for more than a couple of minutes. Hospitals trying to cut costs love this technology.”

That’s why he refers to DDR technology as a cost reducer instead of a money maker. “Facilities needn’t expand for x-ray, and staff and cycle time is optimized,” he says.
“What you could do in two or more rooms, you can now accomplish in one,” Boon adds.
That points to the true benefit of digital radiography—meaning either charge-coupled device [CR] or digital flat panel—which is enhanced workflow, he says. “In addition, when room reduction comes into play, space is freed up for other uses and other modalities,” he says.

But there are other benefits. “Technologists have more positive intimacy with the patient in the DR environment. Also, if the technologists are moving the images through PACS, there’s faster throughput to the radiologist and referring physician,” Boon points out.
Both CR and DDR offer robust digital imaging and advanced postprocessing capabilities. But DDR provides a productivity edge, as it enables greater throughput by automating the imaging processing cycle. While CR enhances workflow compared with film, DR further streamlines the process, enabling facilities to accomplish imaging in fewer steps and, in turn, see more patients in a comparable time period.

Benefits of such an upgrade became evident at Hospital for Special Surgery in Weill Cornell Medical College at Cornell University.

“When equipment reaches its end of life, you have to make a decision whether to replace what you currently have or move to the next level. And as we’re a state-of-the-art facility, DR represented that next level,” says Helene Pavlov, MD, FACR, radiologist-in-chief and a professor of radiology and radiology in orthopedic surgery at Hospital for Special Surgery. “The second important point involves space. Conversion from analog to digital eliminates dark rooms and processing, which opens up more space. Further, the conversion improved our room efficiency as it enabled faster patient throughput.”

Pavlov also points out that DDR conversion runs more smoothly than CR conversion. “It was much easier and more readily accepted, particularly from the technologist perspective,” she says.

“Also, with CR, you’re really not saving [much] time,” says Edward White, assistant vice president for the department of radiology and imaging at Hospital for Special Surgery. “With our DDR room, we can shave off about 30% of time per patient. CR only allows us a few minutes extra time with each case.”

Adds Pavlov, “DDR appears the way you want to go. It’s not only more efficient, but it helps with recruitment of staff and faculty. Also, it’s like a digital camera, where you can instantly view images and determine whether you want to save or delete.”

Burkhart expands on the consumer digital camera metaphor to emphasize DDR workflow benefits. “In older rooms, which were manual, the whole process involved 18 minutes just to get one shot and another 10 or 15 minutes of dark room time and processing,” he says. “But a DDR room is like a digital camera, which is a very smart piece of equipment. Within five to 10 seconds, the operator will get a view of what they just took, and they can determine if it will be adequate.

“Our DDR calls up the record and sees what exam types were ordered,” Burkhart continues. “Once it knows all of that, it automatically sets up a machine for the body type and size and the body part imaged. It will also set up the sequence for the operator and provide instant feedback, which reduces the retake rate down from about 15% to less than one half of 1%. Thus, it’s almost impossible to take an incorrect exposure.”

Infrastructure Issues
Infrastructure—or lack thereof—is another important factor, as infrastructure deficiencies can be a major hindrance for facilities seeking to adopt DR.

“Infrastructure is important because it involves the capture of the image, viewing that image at the workstation, and moving that image information directly to the radiologist,” Boon says. “In an analog environment, the technologist has to move cassettes to a processor, wait for the film to come out, and then move it to the facility where the radiologist is located. DDR enables the image to travel wherever it needs to go in the most time-effective fashion. CR gets you partly there, as it gives you a digital image, but you’re still physically moving cassettes and plates.”

As such, proper infrastructure must be in place before DDR can be implemented. “A facility’s IT department needs to be engaged to take full advantage of digital systems because the speed of image transfer is dependent on the integrity of the hospital’s network, network security, communication with other DICOM modalities, and other infrastructure considerations,” explains Maier. “More digital systems are leveraging capabilities for wireless transfer of DICOM worklist or image transfer, which requires the IT group’s involvement for successful implementation.”

Archetypical Adoption
Implementation at North Dakota-based Altru Health System reflects all of the aforementioned observations. Looking back on the project, Richard Lofgren, radiology supervisor at Altru’s main clinic, recalls, “It all started in 2006 with PACS adoption. Then we decided to implement [digital] technology. After a product evaluation conducted at the end of that year, we decided to deploy a CR/DR mix, purchasing three of FujiFilm’s Velocity suites, which we integrated into high-volume areas, including the main clinic, the hospital area, and our orthopedics department. At first, we focused on CR but later realized that DDR would better improve our throughput.”

“The [DDR] idea emerged from our workflow,” adds Steve Metcalf, Altru’s manager of radiology services. “We’re a high-volume enterprise and, looking at it from a customer service standpoint, we felt we could meet the needs of physicians and patients a bit faster, as we could image more patients in a more time-effective manner.”

“DDR is instantaneous compared to what we did before, and workflow is super efficient,” says Jessica Nielsen, Altru’s orthopedic technologist and clinic supervisor.

When it came to room configuration, the health system didn’t have a great deal of money in its budget for significant modifications to existing x-ray rooms. But, in the end, that didn’t even matter. “We really didn’t have to change the rooms that much,” says Lofgren. “The only major change involved infrastructure, as we needed to add a lot of data drops and electrical outlets to accommodate the DDR equipment.”

Also, Altru was able to reduce its x-ray rooms by two. “DDR had made things so much more efficient,” says Lofgren.

As a result, the health system could use the freed-up space for other purposes. “We created two radiologist reading rooms out of one x-ray room at the main clinic and converted a hospital x-ray room into an interventional suite,” says Lofgren. “Also, we moved the radiologists to a central location. Previously, the radiologists were split between the hospital and the clinic. With PACS and DDR, it doesn’t matter where they’re located. Now, we have a lot more space that can be much better utilized for things such as interventional procedures.”

Other issues that drive DDR implementation include increased patient awareness, says Maier. “Patients are more knowledgeable than ever thanks to the Internet, published research, and media stories that highlight the advantages of digital systems,” she says. “As a result, patients will often ask to have their exams done on the digital systems. In turn, this spurs competition among healthcare facilities.”

But it’s also about employee satisfaction. Staff members appreciate advantages of digital. In fact, as Maier points out, many technologists exposed to the digital environment will avoid working in a facility that remains in the analog world. In a healthcare environment where recruitment and retention are critical, that’s no small consideration.

— Dan Harvey is a freelance writer based in Wilmington, Del., and a frequent contributor to Radiology Today.