Eliot Siegel, MD, FACR, FSIIM

Computer aided detection (CAD) is increasingly utilized in radiology, and is most prevalent in screening mammography where it is reimbursed by Medicare. While CAD may be helpful to the clinician in highlighting nodules and asymmetric or suspicious breast density the clinician may not have otherwise observed or noted, its use is not without legal ramifications.

Important legal questions associated with the use of CAD include to what extent CAD is becoming the legal standard of care in our subspecialty, and whether radiologists or surgeons now feel obligated to follow or biopsy CAD findings as a component of “defensive medicine,” even if they deem the CAD findings questionable.

Also of legal significance is whether radiologists choose to archive CAD markings. And if they don’t, is there a worry that current or even future, improved versions of CAD might later be used in a courtroom setting to show that findings were “CAD evident,” or alternatively, that discarded CAD findings might be deemed “spoliation” (destruction of evidence).

To better address the legal ramifications of CAD use (and non-use), we are conducting an online survey of diagnostic imagers who perform mammography to better understand the extent to which radiologists are using CAD, and their views on the legal ramifications of CAD use. We suspect there are mixed opinions regarding its current utility, and are curious to see if radiologists have concerns about CAD’s potential legal consequences.

Responses to the survey will remain anonymous. The goal of the survey will be to present data at a national meeting and/or publish it in a radiology related publication. The results will also be shared here with the readers of 

All clinicians with experience with CAD in mammography are invited to complete the survey at the link below. Thank you for your assistance.

Jonathan L. Mezrich, MD, JD, MBA, LLM, a former practicing attorney, is a third-year radiology resident at the University of Maryland. Eliot Siegel, MD, FACR, FSIIM, is professor of radiology at the University of Maryland School of Medicine Department of Diagnostic Radiology and Nuclear Medicine and chief of imaging for the VA Maryland Healthcare System.

Articles

CAD may help highlight nodules the clinician may have otherwise missed, but its use is not without legal ramifications. What do you think? Take this survey.

Legal Ramifications of Computer Aided Detection in Mammography

Without much fanfare, the Baltimore VA Medical Center passed its 15-year milestone as the first filmless (with the exception of mammography) hospital on June 23, 2008. Instead of marking the occasion with a big celebration, we took this opportunity to reflect on the many things that have changed and, perhaps more interesting, the things that have stayed the same.

The most visible change is the radical redesign of our radiology reading room (Figures 1 and 2), an effort based on a topto- bottom assessment of all our room design mistakes from the first 10 years of filmless operation. One immediately successful technology in the new installation has been an effective and relatively inexpensive sound masking system along with accompanying sound-absorbing materials.

In combination, these environmental additions not only reduce noises from outside the room (such as those from our MR scanner next door) but also minimize the cacophony associated with conversations, dictation, and other routine noises within the room itself.

Other innovative features include icons on each workstation to control overhead lights, individual LED task lighting, adjustable monitor and table heights to accommodate sitting or standing, individual ventilation controls, ergonomic chairs (Figure 3), modular partitions, and biometric and key fobcontrolled room entry. These-as well as unconventional and evolving touches such as scented candles and a treadmill workstation- have combined to create a low-stress, productive, and pleasant place to spend the working day.

In addition to the surroundings, many aspects of our daily work have changed. We now dictate using a speech recognition system. The system requires about 15% more time for a radiologist to dictate an individual case but has reduced our report turnaround times from hours to minutes and report signing times from days to minutes. Our new radiology residents seem to be completely comfortable with the system and do not understand how we ever managed to organize our thoughts in the “old days, when you really couldn’t edit the report once it was spoken, without rewinding and dictating again.”

We now routinely use an advanced workstation and dictate directly from the 3D workstation or use it in almost every case reviewed on our PACS. Our average body CT study has increased from approximately 60 to around 900 images, which are required for review of all CT studies in multiple planes and using maximum intensity projection and volume rendering. Unfortunately, as was the case in 1993, many features that are routinely required, such as fusion for PET/CT and arithmetic summing of thin into thicker sections, are not available on our PACS but must be accessed using a specialized workstation.

Our medical records became entirely electronic within a few years after we acquired our PACS. This provides us with complete access at all locations to the entire patient record (although we are required to open two simultaneous windows and log into the systems separately, which is cumbersome).

Routine access to the Internet from the PACS workstation now allows us to use search engines such as Google or the radiology domain–specific Yottalook. This has substantially increased the frequency with which we look up interesting and obscure information as part of the image interpretation process.

We communicate with clinicians and other physicians by e-mail and via our imaging reports, which are now available almost immediately. As a result of ubiquitous access to images throughout the enterprise and rapid report turnaround, clinical colleagues now visit for in-person consultations only rarely, especially for general radiography where the frequency of these consultations has dropped to less than one-seventh of what it was in 1993.

We are finally making the transition from film to digital mammography, based on the encouraging results of the Digital Mammographic Imaging Screening Trial and recent improvements in workstation-based interpretation of mammograms.

The basic human-machine interface with the PACS has not changed significantly. The original model, based on Adobe Photoshop with various icons and/or pull-down menus to change window/level or point, zoom, magnify, and draw a region of interest using a mouse or trackball, has not changed perceptibly. This is despite the fact that the way in which a radiologist interacts with a workstation when interpreting a large data set of CT, MR, or other modality studies with or without comparison studies has changed dramatically.

This process used to be more passive, similar to that involved in film interpretation, but it has now evolved into a much more interactive  and dynamic experience in which the radiologist/clinician navigates through the images using multiple planes/perspectives. The tremendous amount of work that has gone into improving the human-machine interface in the computer gaming and aviation industries has, regrettably, not yet been adopted by PACS vendors.

The way in which we sign on to and off from the PACS has not changed since 1993. Despite innovations in more efficient ways of signing on to information systems (such as the use of the Lightweight Directory Access Protocol, which can support a single user name and password shared among multiple information systems), our hospital/radiology information system, PACS, speech recognition system, and MR, PET/CT, nuclear medicine, and 3D workstations all still require separate sign-ons. Equally important, newly available technologies that can provide automatic log-on and log-off, such as radiofrequency identification, have not been implemented at our facility.

Capturing cases to a digital teaching file or tickler file system remains a surprisingly cumbersome process. We can send individually selected cases or whole series to a specific destination folder for future reference, but this does not allow us to capture the images to a structured teaching file, to de-identify the studies for Health  Insurance Portability and Accountability Act purposes, or to facilitate offline access. An Integrating the Healthcare Enterprise profile, Teaching file and Clinical trial Export (TCE), describes a way to select, deidentify, and then export images and descriptive information from a PACS to a teaching file system. Unfortunately, no commercial PACS vendor or advanced visualization vendor currently supports this profile.

We still have no way to efficiently share images with clinicians, research collaborators, or other healthcare workers outside our own facility. In 1993, we printed film for outside clinicians, amounting to approximately 5% of our volume of studies. We found this to be less than satisfactory because of the limited quality of the dynamic range of digital films and the extra resources and time required to print and send the films. We now transfer studies in DICOM format onto CDs-a process that brings with it new problems, inefficiencies, and quality issues. The creation of CDs requires additional time for technologists or administrators to burn, handle, and mail or give the CDs to patients. Programs embedded on the CDs frequently require administrative access that clinicians do not have on their own PCs, use software that conflicts with other programs, or use nonintuitive software. We have as many complaints about the CDs now as we used to have with printed films.

The amount of time required to retrieve images to our workstations has not improved. In fact, image retrieval time has actually increased slightly because of the complexity of imaging studies and the number of images per study. Solutions are available in the larger world of electronic information management. Large image sets, such as Google Earth and MapQuest maps, are not stored locally on a PC but are “streamed” on an as-needed basis to the user. This approach allows almost immediate on-demand review of images.

It is likely that medical imaging will transition to server-side rendering using this type of streaming technology over the next few years. However, only a minority of PACS vendors are currently investigating or offering this technology.

PACS has not had a fundamental impact on the ways in which we communicate urgent/important findings to our colleagues. We have faster turnaround on reports but do not know whether these reports have actually been reviewed, much less acted upon. Communication is still primarily one way.

In our department, we manually track urgent/important findings and notify the requesting clinician or, when that provider cannot be contacted, another clinician designated with this responsibility. We later check to determine whether a recommendation, such as a follow-up CT, was actually initiated. If not, then we communicate with the clinician again to ask about the reason for the lack of follow-up. This critical communication issue continues to have a major impact on patient care. In 1993, we anticipated that the process would be automated well before 2008, but this has not been the case.

Fifteen years ago, we anticipated that the extraordinary ability to capture all aspects of the image acquisition, interpretation, and communication process would dovetail nicely with similar access to patient electronic medical records to provide the outcomes data that radiology very much needs to defend rapid technological change and innovative techniques. The hope was that it would be a relatively simple matter to automatically follow the effects of different imaging techniques and technologies “downstream” to provide real quantitative metrics about costs and benefits. Although many investigators are certainly at work gathering these data, for the most part they continue to do it with hard and often manual slogs through the records. We have not yet capitalized on the research potential of all the information we now capture.

One final aspect of our work has not changed: the sense of exploration, adventure, and-every once in a while-magic that we have somehow managed to preserve over these past 15 years. Our imaging informatics team and our clinical radiologists from the University of Maryland School of Medicine and the Baltimore VA Medical Center continue to question the status quo in diagnostic imaging, to explore new technologies from other domains, and to maintain a healthy degree of skepticism and curiosity about our changing practice of diagnostic imaging.

Without much fanfare, theBaltimore VA MedicalCenter passed its 15-yearmilestone as the first filmless(with the exception of mammography)hospital on June 23,2008.

In PACS, 15 years makes a world of difference

If a man does not keep pace with his companions, perhaps it is because he hears a different drummer.

Let him step to the music which he hears, however measured or far away.

If you were to ask any veteran radiologist what the best and worst parts of his or her radiology practice are today, you might get the same answer to both questions: technology. While technology is what attracts many medical students to the field in the first place, it is also one of the primary variables increasing stress in the radiology workplace. For better or worse (and till death do us part), radiologists and technology go hand in hand. It is therefore not surprising that technology brings out both the best and the worst in its practitioners.

The relationship between technology and stress likely accelerated around 1936, when Hans Selye first described the general adaptation syndrome, otherwise known as stress. Within the next few years, several important technological inventions specifically related to the computer occurred, including the development of digital electronics by Claude Shannon in 1937, the Atanasoff-Berry computer in 1938, and the ENIAC in 1943. From that point on, technology and stress became inextricably intertwined.

A number of factors contribute to increasing levels of stress in the radiology workplace today; many are directly job related, and others are unique to the individual. Job-related stressors include the imbalance of supply and demand for both radiologists and technologists, the increasing size and complexity of imaging data sets, ever-changing imaging and information technologies, decreasing reimbursements, and heightened medicolegal risk. Internal stressors unique to each individual involve genetics, lifestyle, and personality. Examples of type A personalities abound throughout medicine, as the profession often self-selects for highly motivated, driven, and goal-oriented individuals who place tremendous internal stress on themselves in their pursuit of excellence.

The convergence of these increasing stressors, both external and internal, and rapidly evolving technology has created an atmosphere ripe for job burnout, which represents a combined physical, mental, and emotional response to repetitive levels of intense stress within the workplace. The stress itself represents a temporary state of mind that typically dissipates over time, while burnout represents a state of emotional fatigue that is long lasting. The end result is job-related exhaustion, cynicism, and ineffectiveness. In the end, many radiologists and technologists elect to drop out.

Surprisingly, little scientific study has been done within the radiology community regarding the relationship of stress and technology. While technology has been championed as the catalyst for productivity gains and advanced clinical care, little is really known about its impact on cumulative stress. At the same time, questions remain unanswered concerning how specific factors such as personality affect perceived stress levels from one individual to another and how we can use this knowledge to customize technology to simultaneously enhance job performance and minimize stress.

In an attempt to facilitate this understanding, we have designed a survey that investigates the relationship of personality, perceived stress, technology, and practice environment. The survey is available in both print and electronic versions and can be completed in 12 to 15 minutes. All responses will remain anonymous and confidential, and summary data will be made available to all participants.

Here is how we see technology evolving in the near future.

Radiologist R enters the sound-proof high-tech reading suite after being recognized by the retinal scanner. Before the environmental factors are adjusted to his individual preferences, an "affective scan" evaluates his facial expression, heart rate, body temperature, and galvanic skin response. Based on a combination of affective and personality data, the computer recognizes our radiologist as unusually anxious this morning (due to the combination of an argument over his daughter's new tattoo, the ticket he received on his way to work, and his favorite football team's loss in the playoffs). The ubiquitous computing network adjusts the environmental factors accordingly by dimming the lights, setting the air conditioning to 68 degrees and high ventilation, playing Pachelbel's Canon in D Major, and displaying the amber external light that suggests that a visitor enters at his or her own risk. The network directs the computerized ergonomic chair to the incline position, presents a cup of ginseng tea (no coffee today!), and pulls up the CNN Financial Web Page (knowing Dr. R's stock portfolio was up 2.1% yesterday). As Dr. R begins to relax (as detected by the affective computing sensors), the computer asks if he is ready to begin work.

Radiologist R puts on his computerized headset and issues the verbal command, "Open unread CT work list." Based on Dr. R's personality and technology profiles, affective data inputs, and recent workflow data, the computer selects the optimum hanging protocol and navigation formats, user interface, and decision support tools. As the unread CT work list is opened, Dr. R realizes that his supposed close friend and colleague Dr. S left 20 cases on the queue from the prior day, including a postoperative neck. As soon as this information is registered, the computer senses his heightened anxiety and responds in kind by adjusting the navigational device (foot pedal instead of mouse), selecting the "simplified" UI, and 1:1 display format. The reading queue is rearranged to display the noncontrast trauma head CT first, allowing Dr. R to regain his composure. Before beginning, Dr. R directs the PACS to send the unread postoperative neck CT case to Dr. S's reading queue with an attached audio file that would not pass the scrutiny of this journal's censors.

After successfully completing the first five cases, Dr. R begins to settle in and relax. As he does, the computer senses his more relaxed state and makes "on the fly" adjustments accordingly. As he opens up a chest CT angiography exam, the computer notifies him that another user is reviewing the same study. Dr. R decides to consult electronically with Dr. P, the pulmonologist, as she simultaneously reviews the same exam in the mobile ICU. Dr. R instant messages Dr. Q to notify him that he is reviewing the same case. After a few kind words are exchanged (using the pleasantries template), Dr. R directs the computer to use Dr. Q's default settings for the consultation. One might not even realize they were reviewing the same exam or using the same PACS, given the vast differences in the presentation state, reconstruction algorithms, workstation tools, and user interface. In the old one-size fits-all days, every user was forced to use standardized software that allowed for a bare minimum of customized features.

The first generations of PACS trained the users rather than the other way around. Now, with user-specific personality and technology profiles embedded into the sign-on and adjustments made based on real-time affective data inputs, workflow is consistently optimized to each end user's preferences and abilities. One single CT data set can be processed, displayed, navigated, interpreted, and reported using completely different schemas, which to the untrained eye appear completely different from one another.

As Dr. R continues his work, the computer continuously updates its user-specific database, based on numerous variables (including the modality, exam size and complexity, clinical indication, affective state, time of day, work list size, and recorded abnormalities). These data are, in turn, processed to automatically provide future workflow recommendations and contrast with other users with similar personality and technology profiles. This step has served to provide valuableshort-cuts, in a continuous attempt to optimize each user's productivity, in accordance with his or her unique skill set, personality, and technical aptitude.

While this scenario may seem futuristic and far-fetched, it is actually not out of the realm of near-term reality. Recent affective neuroscience and psychology studies have reported that human affect and emotional experience play a significant, useful role in learning and decision making. Affective-based personality assessments can be a valuable resource in optimizing job selection and performance. These findings validate our experiential knowledge that tells us some people are better suited for some professions.

Many of us have experienced the notion that internists think and behave differently from surgeons, who in turn are different from radiologists. But in the end, we must ask ourselves where the similarities and differences among the radiologist community begin and end. How can we use this knowledge to make better informed decisions regarding subspecialty training, job selection, and practice planning? As radiologists everywhere experience increasing levels of job-related stress, what impact does this have on overall work performance, and what can be done to alleviate these stressors? Does technology serve as an enabler or impediment to stress, and which types of technology are best suited to which types of personality?

While technology continues to evolve at a breakneck pace, the engineering that goes into these technical advances is typically conducted in a vacuum. To a large extent, engineering is designed by technologically savvy nonclinicians who do not always appreciate the diversity of the end-user population. The one-size fits-all approach does not take into account considerable differences in personality and affect, education and training, technical skills, and susceptibility to stress. An adaptive approach to technology development is necessary, but before that can be done, it is essential that we better understand similarities and differences in personality and stress.

We encourage all of our readers and colleagues to play an active role in this endeavor and take a few minutes out of your stressful schedules. In addition to letting off a little steam, responding to our survey should be fun, informative, and maybe a little therapeutic. We thank you in advance for your participation and look forward to using this information to serve the betterment of the community. You can complete the survey at 

Dr. Reiner is director of radiology research at the VA Maryland Health Care System, and Dr. Siegel is vice chair of diagnostic radiology at the University of Maryland School of Medicine and chief of radiology and nuclear medicine at the VA Maryland Health Care System.

Stress reflects dichotomy in march of progress

The Oakland Athletics medical and training staff, preparing for spring training prior to the 2004 baseball season, considered the options for obtaining and reviewing radiographic studies. In past seasons, players went by van, five or so at a time, to local imaging facilities and offices in Phoenix and then returned to training. The process was repeated daily until examinations for the 80 or so players were completed. The films were interpreted, filed, or retained at the spring training site for later review by the orthopedists and medical staff and then traveled with the A's to California for the start of the season.

The team orthopedist's private office had recently converted to digital imaging, and the company providing the filmless system was asked about the feasibility of digitally acquiring and transmitting the images obtained in Phoenix for review in Oakland or at home. A local mobile x-ray operator using a digital imaging system in Phoenix similar to the one installed in the orthopedist's Oakland office agreed to come to the spring training site, and 11 radiographic procedures were performed in one morning.

The images were then transmitted to local radiologists as well as to the orthopedic offices in Oakland and nearby San Ramon. The team orthopedist was able to review the images the next morning when he came in to the office and made immediate determinations as to each player's status and what other examinations might be needed. All this took place within one day. No player had to leave the training facility. The training staff had all the images available for the rest of the season on their laptops and on CDs. The power of digital imaging and PACS brought improved efficiency, patient convenience, service, and cost savings (Figure 2).

In increasing numbers, orthopedic offices are acquiring and operating imaging equipment. Any assessment of the requirements for a filmless imaging system in orthopedic offices requires understanding of this trend. With the emergence of MRI, new techniques for joint replacement, and less invasive joint disorder examinations such as arthroscopy, orthopedic surgeons rely more heavily than ever on imaging procedures to assess their patients.

Their offices now serve as mini-imaging centers. More efficient patient management that avoids referrals to remote facilities and captures the technical revenues from these examinations has accelerated this trend. Patient acceptance is excellent. Patients can often have imaging procedures performed and reviewed and see their treating physician all in one visit.

For optimal performance, the systems used for converting orthopedic offices to filmless must have attributes similar to those that exist in the PACS installed in radiology departments and imaging centers:

- User-friendly software and display devices;

- PC-based platform and software compatible with business systems already in place;

- complete multimodality viewing on all workstations, including tiling or stack mode review of MR examinations;

- immediate availability of images via wired or wireless networks for orthopedists and patient review;

- ability to transmit images offsite for consultation and primary interpretation by radiologists;

- capability to e-mail images from all workstations to referring physicians and other necessary individuals;

- ability to burn CDs of imaging studies for referring physicians, patients, review in the operating room, conferences, and research collaborations;

- Health Insurance Portability and Accountability Act compliance and security of images and patient information; and

- affordability, with costs comparable to hard-copy screen-film-based studies.

Orthopedic surgeons face extremely heavy caseloads in their days in the clinic, and workflow must be efficient. If imaging procedures are required, these need to be available at the time the orthopedic surgeon sees the patient and discusses treatment options and progress.

The relatively rigid scheduling of patients common in hospitals, based on staffing and radiologist availability, is not acceptable in the orthopedic office. Patients undergoing imaging procedures are generally being seen by their physician on the same visit, most often immediately following the completion of the imaging procedure. When the patient is in the examination room, the images, as well as related prior exams, need to be available. This places a different demand on the x-ray unit.

Almost every imaging procedure performed in an orthopedic office is reviewed with the patient. This custom requires a means for transmitting the images throughout the clinic or office. Ethernet and wireless connections facilitate image delivery and make the ease of viewing software critical. Speed of transmission and immediate patient access for viewing images are less critical in radiology departments. Similarly, radiology departments generally have in place sophisticated infrastructure from decades of filmless experience with nuclear medicine and CT and MR devices, along with backup technologists and staff familiar with these systems. No such prior experience is common in orthopedic offices.

When orthopedic surgeons' offices pursue the transition to filmless imaging, several options require consideration. In addition to selecting the appropriate partner, these surgeons and their staff also face a variety of technology choices. The primary alternatives for converting offices from hard-copy screen-film to soft-copy filmless are direct radiography and computed radiography. CR devices use phosphorous plates in cassette systems, while DR uses a noncassette image receptor, such as amorphous selenium or silicon, or CCD detectors.

There is no longer any debate over the quality of images produced from either digital technique in standard radiographic examinations. The decision should be based solely upon the functionality of the technology and its cost-effectiveness in a particular practice. The chief attribute of the more expensive full-room conversion involved with DR is the reduction in the number of steps required in the radiographic process and, debatably, superior image quality compared with CR.

We find that while the higher DQE of DR produces less noise in the image for a given dose, CR and DR produce equivalent images, assuming dose adjustments are made for each technique. Both CR and DR produce clinically acceptable images, in most cases superior to screen-film, especially when employing the inherent advantages of digital imaging: enhancements such as window and level (adjustments of brightness and contrast), magnification and zoom features, onscreen measurements, and angle calculations.

DR has been touted as leading to improved workflow and throughput. The issue of workflow and throughput was largely anecdotal until recently, when studies emerged specifically addressing the subject (Reiner, Andriole). These studies performed at several of the most prestigious institutions by thought leaders in digital imaging and PACS have concluded that, except in unusually high utilization environments (facilities operating at 80% or greater capacity utilization), DR has no economic, workflow, or throughput advantage over CR.

All these studies indicate that, while DR is technologically more compelling, when technologist productivity, equipment purchase, maintenance costs, procedure volumes, and capacity utilization are considered, the productivity advantages of DR are disproportionally offset by its associated higher equipment purchase and maintenance costs. The cost differential can amount to $50,000 to $75,000 per year (Reiner).

Features and benefits available on the preferred digital imaging systems for orthopedic offices include electronic preoperative planning tools, such as implant templating and "stitching." This creates long films from overlapping or separate images that are seamlessly fused electronically for full leg and spine viewing and subsequent measurement of Cobb angle, leg length, and other calculations (Figure 1). A variety of packages can perform this function, and the ones that employ anatomically based algorithms are invariably better for the user.

Similarly, the ability to perform technique-related window and level adjustments on the images prior to stitching is extremely desirable. The cost benefit of electronic templating and stitching has yet to be validated, but they clearly provide for a permanent archived record of both the native and measured images, and image quality is improved over conventional screen-film images. Attention to magnification and calibration of images is crucial to this process, and the more advanced software packages address this need.

Another important factor for orthopedic offices in making the CR versus DR decision is the relatively restricted positioning imposed by fixed DR detectors. In an orthopedic setting, certain specialized views, such as Merchant, Sunrise, and curved cassette views (e.g., shoulders), can readily be achieved with CR plates and readers but not DR devices.

The perception that CR is yesterday's technology has not proven accurate. Institutions and clinics in the U.S., including the most progressive and technologically advanced, continue to acquire CR devices over DR by a factor of more than seven to one. Advances in plate and CR reader technology, as with DR receptor technology, continue to improve system performance and speed. The decision of DR or CR is an economic one best addressed by each institution and its vendor partner, based on local cost issues and operational demands. The overall economic investment is weighted strongly toward CR in most clinical settings.

Virtually all orthopedic offices considering filmless imaging simultaneously evaluate the benefits of the electronic medical record. The conversion to a paperless office has been the subject of recent attention from both the government and the lay press. Studies have begun to demonstrate the cost-effectiveness of this technology as well as the benefits to patient care. It is clear that a paperless conversion will go hand in hand with the filmless office, and that these technologies and systems will need to be integrated. The degree of integration can range from straightforward sharing of header file demographic information between the systems or use of simple work list management to full consolidation wherein film files reside in the same folder on a desktop in the office.

Here again, as with the CR/DR debate, cost of the integration and functionality will be the primary drivers. In this environment, Web-based systems seem to have great appeal, as the size and complexity of image files dwarf the capacity and speed of the retrieval requirements for hard drive and onsite media-based archival systems in the larger, busiest offices. Both EMR and digital imaging implementers are continuously working on the ultimate goal of the fully integrated system. Until that effort is completed, toggling back and forth between EMR and digital imaging software programs on the desktop affords a cost-effective method for implementing a paperless and filmless office.

The economic justification for converting orthopedic offices from film to filmless depends heavily on the nature of the practice, its volume, and specific workflow issues. To make a meaningful comparison of the costs of film-based and filmless systems, the office managers must understand its fixed and variable costs, including storage, number of retakes and lost films, retrieval, and staff productivity, as well as other hard costs associated with film-based technology, such as film, chemicals, folders, stickers, and labels (Table 1).

Orthopedic offices must also compare the tax advantages and incentives of capital equipment acquisition versus the more familiar operating expenses associated with disposables and consumables. These models have been refined, and breakeven analysis and return on investment calculations are important considerations. It is in these models that the workflow and throughput determinations discussed have the greatest impact on economic decisions in most offices (Table 2).

While we recognize the emotional impact of economic, self-referral, and turf issues, orthopedic surgeons are employing more and more imaging procedures in their practices and increasingly insourcing these services. This trend will undoubtedly continue, and imaging by nonimaging specialists has become a reality in contemporary healthcare delivery. We estimate, for example, that there are 80,000-plus offices in the U.S. performing routine nondental radiographic procedures on a daily basis. Orthopedic offices constitute a large portion of those offices, performing far more procedures than any of the other categories. As a result, many radiology groups and practices are dedicated specifically to remote interpretation of studies generated outside of radiology departments and practices.

The Internet and broadband access to images permit faster turnaround and availability of specialists particularly skilled in musculoskeletal imaging, especially MRI, as well as projection images. Local radiology groups have begun to accept the "half a loaf" philosophy of interpreting the images while not participating in the technical revenues. The decision of an orthopedic group to contract with local radiology groups has merit. It creates a tighter bond between the orthopedic group and its radiology associates and encourages a more collegial relationship, as many of the patients will be hospitalized and require imaging services from the local group.

Remote interpretations have typically featured specialists with outstanding credentials in musculoskeletal imaging, a luxury often not afforded by smaller radiology groups and practices. Service (fast, accurate, and clear reports of procedures) and price influence the decision about which individual or group will be selected to interpret the studies obtained in orthopedic offices.

Increasingly, orthopedic surgeons' offices also employ part-time and full-time radiologists in increasing numbers. This decision is justified, as some groups are now performing well over 3000 MRI and 50,000 projection-imaging procedures per year. The in-office orthopedic surgery imaging market will continue to grow as much as 20% per year, according to some estimates, and radiology groups need to make a conscious decision to be in or out of this part of the imaging business. Pretending that it does not exist will not be in the best interest of either the practice or patients.

It is always treacherous to predict the future in diagnostic imaging, healthcare, or technology. But it is clear that existing modalities are finding their way into orthopedic practices at a rapid rate. Plain-film (now filmless) imaging, MRI, CT, and DXA are common in most large orthopedic practices and moving into smaller ones. New software for advanced image processing, 3D reconstructions, higher resolution imaging, and functional evaluation of musculoskeletal structures and diseases is already present in many academic and clinical practices.

The advent of broadband communications and user-friendly software leads to more efficient and higher quality orthopedic practice. Integration of filmless capability with paperless EMR systems as part of healthcare delivery will be the major step forward for orthopedic practices in the next five years, and it will fulfill the mandate of presidential and congressional proclamations that EMR will be the standard in medical practice.

Orthopedic surgeons and their offices are actively engaged in the conversion to filmless environments. The challenge for industry and clinical leaders is to make the adoption of this compelling technology affordable, reliable, user-friendly, and efficient.

The imaging community will include both radiologists and nonradiologists, and their cooperative spirit and relationships will create a better, more cost-effective system for patients. That should be the goal of all participants in the pursuit of the paperless and filmless healthcare enterprise.

Andriole KP. Productivity and cost assessment of computed radiography, digital radiography, and screenfilm for outpatient chest examination. J Digit Imaging 2000;15:161-169.

Andriole K, Luth DM, Gould RG. Workflow assessment of digital versus computed radiography and screen-film in the outpatient environment. J Digit Imaging 2002;15(1):124-127.

Reiner B, Siegel E, Hooper F, et al. Technologist productivity in the performance of digital radiography: CR vs. DR. Radiology: Chicago (in press).

Siegel E, Kolodner RM. Filmless radiology. New York: Springer-Verlag, 1999

Eliot Siegel, MD, FACR, FSIIM

Articles

Legal Ramifications of Computer Aided Detection in Mammography

In PACS, 15 years makes a world of difference

Stress reflects dichotomy in march of progress

Digital imaging makes inroads in orthopedics