Real-world installations migrate into digital x-ray

Speed, quality, and labor savings all factor into decision- making as more centers move away from film

BY GREG FREIHERR

Dennis C. Carroll, chief technologist at Methodist Hospital, takes a digital chest radiograph with the Revolution XQ/I. The Houston hospital performs about 125,000 x-rays annually. All are done using CR or the Revolution.

Most installations of new digital technology have been showcase sites or test beds, propped up by special circumstances. Vendors need them as living proof that their equipment really works in a clinical environment and not just in an engineering lab.

But more and more, mainstream sites are testing the digital waters for real. In many cases, they install computed radiography (CR) as a first experience, hook into a PACS, then pick a digital radiography (DR) product, comparing output and performance advantages among the various products.

While customers have typically been drawn to established companies, no discernible pattern has emerged with digital radiography. Customers so far have been as likely to buy from smaller competitors as from major vendors.

Looking for leading-edge technology, early adopters at teaching hospitals may buy from more than one vendor, testing and comparing the systems' advantages and the character of the underlying detector technology. Hospitals hoping to increase efficiency through PACS may mix and match networking technology and CR and DR systems from multiple vendors, relying on DICOM protocols, vendors' assurances, and their own sense of adventure.

Administrators at St. Louis Children's Hospital have chosen Cares Built, whose digital detector is based on complementary metal-oxide semiconductors (CMOS) technology. CMOS offers extraordinary spatial resolution of 7 line pairs per mm, according to Mike Albertina, the former director of radiology services who developed the plans for installing PACS at the hospital.

"No one can come close to this resolution," said Albertina, who now serves as the hospital's PACS consultant.

Digital x-ray is an integral part of the PACS implementation at Children's. In evaluating various DR approaches, Albertina considered the ability to retrofit the existing conventional x-ray equipment with a Cares Built detector, as well as field serviceability.

"Everyone else has one huge plate," he said. "Cares Built has individual CMOS chips."

The downside to choosing the company as a DR vendor is that its digital product has not yet been cleared by the FDA. When clearance is given, Children's will be the company's first clinical site for digital x-ray technology, Albertina said.

Three CR units, all from Kodak, are already in place at the hospital. Two are in the main radiology department, with a third in the emergency room. DR systems will eventually replace the CR systems for all but portable x-ray products, if the Cares Built technology pans out.

In keeping with its pioneering spirit, Children's was an alpha site for Kodak, just as it expects to be one for Cares Built. Alpha sites receive a lot of attention from vendors. Purchase agreements with Cares Built and Kodak included statements that the companies provide staff on site to work with the products, according to Albertina.

"We can help them develop these systems and tweak them the way we feel they should be tweaked to meet our specific needs," he said.

COST-JUSTIFICATION

Being a leader is part of the equation that defines cost-justification. Massachusetts General Hospital, for example, has signed a multiyear asset-management program with GE Medical Systems to deploy equipment representing multiple modalities and PACS.

"We will be installing equipment with a list price of $40 million for which we are paying $23 million," said Patrick Jordan, MGH administrative director of radiology.

Without such help, the cost of CR readers and direct capture equipment can be a budget buster. New DR systems are more than twice the price of film-based products, listing at between $400,000 and $600,000. Yet to institutions dedicated to going digital, capital expenditures are secondary.

"We're at the point where it would snot matter if we couldn't justify DR," Jordan said. "It is state-of-the-art technology and that is where we need to be."

Even at MGH, however, administrators must acknowledge economic realities. Projected savings, performance expectations, phased implementation, and retrospective analyses are being combined as part of a master plan aimed at achieving long-term savings.

Four years ago, MGH began converting its radiology operation to digital. By the end of this year, the radiology department will be reading soft copy for all modalities except mammography. Digital radiographs are being generated through the use of five CR units. ER x-ray is being converted to digital with the installation of GE's Revolution XQ/i. As older conventional x-ray systems are decommissioned, DR products will be installed in their place. MGH also has plans to implement digital technologies from other companies, including Hologic and Canon.

Digital x-ray serves as a critical link in the chain of equipment leading to cost savings mandated by upper management. Edicts from the top, issued in 1996, called for cost savings for imaging operations of 25% or $7 million by 2000. In absolute terms, MGH has achieved $6.7 million in savings, according to Jordan. Utilization has risen dramatically over this time period, however, adding another $10 million in cost avoidance. Contributing about 40% of these savings was the conversion to voice recognition, which allowed a substantial reduction in labor. Replacing CR with DR will add further labor savings.

"We are the poster children for embracing operations improvement," he said.

CRUNCHING NUMBERS

Cost- and time-efficiency calculations have been used by vendors to justify the purchase of digital x-ray systems, as well as to determine whether or when more will be installed. These calculations help provide the financial justification that administrators demand.

One productivity calculation assembled by Swissray in support of its digital radiography products compares the time needed to do a standard exam with film, CR, and its own brand of digital x-ray technology. CR companies may debate the bottom line, which shows CR actually taking seven seconds longer than film processing, but evidence in the imaging community suggests that these numbers are very close to reality. Preliminary studies of film, CR, and GE's Revolution XQ/I digital radiography system at Methodist Hospital in Houston indicate that a chest x-ray on film takes 6.43 minutes, on CR 6.76 minutes, and on DR 2.77 minutes.

"CR is actually slower than film," said Dave Workman, radiology administrative director at Methodist. "If you just go through the various steps associated with using film or using CR, you'll see that the number of steps is about the same, but you obviously require the technologist to have more skills with CR."

CR and DR offer the same advantages, however, when getting the image to the patient, Workman said. Time studies done at Methodist indicate that DR and CR each took an average of about two minutes for the image to get to the radiologist, compared with two hours and 26 minutes with film.

The savings add up when large patient volumes are involved. Methodist performs about 125,000 x-rays annually. All of them are now being conducted using CR or a dedicated digital chest unit.

The advantages have come mostly in reduced labor, not film cost, even though vendors often point to savings in film and chemistry as the natural outcome of going digital. Methodist, for example, is totally digital, but its annual film budget is still $800,000, only a 33% decrease from 1997.

"We are a PACS hospital that still prints a fair amount of film, but we're trying to phase it out," said Dr. Thomas D. Hedrick, medical director of radiology for the Methodist Healthcare System.

Administrators at Rex Hospital in Raleigh, NC, founded their PACS around digital radiography as provided by CR systems. This 500-bed hospital proceeded cautiously, first installing two single-plate CR readers in the ER in May 1998.

"We wanted redundancy, because this was our first step into the digital world," said John Contrael, director of radiology services at Rex.

The next CR installation was a multiplate reader in the outpatient department followed by a fourth CR in the ICU/surgery area. Still to come is a CR system for the main radiology department. These installations are part of a plan that will lead to the networking of MRI and CT into the hospital's PACS and, eventually, the installation of workstations throughout the hospital and in physician offices. Nowhere in this plan, however, is there any mention of DR systems.

"They are just too darn expensive for your average application," Contrael said. "CR offers the affordability and flexibility. Plus, CR has been out there for at least 10 years, so it is a proven modality."

OUTPATIENT SOLUTIONS

Few users of imaging equipment are more aware of economic realities than imaging centers. RadNet Management of Los Angeles owns 38 freestanding outpatient centers. Four are fully digital with the exception of mammography.

"Eventually they will all go digital," said Dr. John V. Crues III, RadNet medical director. "These four were selected first because they are our busiest sites."

Foremost among the reasons for going digital is the financial consideration, according to Crues. Digital radiography, along with other digital modalities, improves efficiency, cutting the cost per exam. Capital expenses are minimized as well.

Tower Imaging–Wilshire in Beverly Hills, CA, the company's flagship center, was built about two years ago to take the place of three older facilities in the RadNet family. Three general radiography rooms were replaced by two rooms with digital systems at the Wilshire site. Eliminating darkrooms and reducing the number of exam rooms has led to a substantial drop in full-time equivalent positions, and with state-of-the-art technology, facilities can hire and keep the best quality workers, Crues said.

Other advantages to using digital radiography include the ability to obtain and transmit results to referring physicians rapidly, making for happy patients and physicians.

"The reputation we've gotten in the community is that a patient can come in and get the study and leave immediately, not having the long waits that they were used to before," Crues said. "Our market share in the community has increased because of that."

Hidden dangers and challenges can slow the process rather than speed it, however.

Both DR and CR require that the work process be reengineered, and getting staff to accept digital x-ray represents a major challenge, according to Contrael at Rex Hospital.

"There are a lot of training costs, a lot of meetings," he said. "To get this to work you need somebody who has the vision and who is able to communicate that vision."

Contributing enormously to expenses at MGH has been the effort to get referring physicians to participate. One-third of referring physicians did not have personal computers, and MGH had to expend its own money to buy PCs and train these doctors, to Jordan said.

In the end, every decision is an individual one, dependent on the facility's unique situation and the disposition of its staff. Cost-justifications, implementation plans, and ultimately equipment choices are part of the process. If MGH's Jordan is correct, that process will lead inevitably to the adoption of digital x-ray.