Digital imaging management steps into orthopedic realm

Although most orthopedists have heard of PACS or seen the software on display at a medical conference, few have had the time to learn about it in detail. A growing number of orthopedists are contemplating integrating PACS into their practice, however, and understanding filmless radiology prior to purchase and implementation is critical.

Filmless radiology, also referred to as filmless or digital imaging, allows data to be displayed on a monitor and the digital x-ray image to be manipulated, duplicated, transmitted, and saved within seconds. To decrease reliance on film radiographs, orthopedists may consider switching to a filmless radiology system that uses digital or computed radiography (DR and CR, respectively), said Dr. Herbert Alexander, president of Alexander Orthopaedics in Ketchum, ID, in the American Academy of Orthopedic Surgeons (AAOS) 2004 Online Bulletin.

With DR, specialized hardware exposes an x-ray image onto an electronic apparatus and then directly converts the x-ray beam into a digital image without the use of a cassette or exposed plate of any kind, Alexander said.

CR, on the other hand, uses conventional x-ray equipment and special cassettes. These contain an imaging plate coated with storage phosphors that are activated with a low-energy laser to capture x-rays. Once the exposure is complete, the CR reader converts the x-ray into a digital image. Presently, most orthopedists are opting for a CR filmless radiology system due to lower cost and interoperability with existing x-ray equipment, according to Alexander.

To manipulate and view the digital images created with DR or CR, as well as digital CT, MRI, or ultrasound images, PACS software is required. A PACS can be purchased as separate or complete components including:

• a server to store images for immediate retrieval

• a permanent mass storage unit to archive images on disc or tape (like a jukebox)

• computer workstations with high-resolution monitors

• a printer to provide hard copies for patients, if necessary

• a communications network to unite all components

Special tools and features within PACS software allow orthopedists to magnify, zoom in on, rotate, and flip images, as well as adjust contrast and brightness and measure angles and distances. Instead of writing on film, information can be saved, deleted, or redrawn onto the images. As an additional benefit, digital templating can be used for alignment, sizing, and planning in the OR.

Orthopedists should find a PACS designed by and for orthopedic surgeons, Alexander said. Orthopedists require software written specifically for them, not other specialists, and need features and functions that are customizable to their daily tasks.

As vendors have discovered the income potential from the sale of PACS to orthopedists, they are aggressively pursuing the market, some with products that may not be orthopedic-specific. Through due diligence, orthopedists and administrators can separate the wheat from the chaff. Physicians should shop around, talk to other orthopedists, interview vendors, and view demos and exhibits at conferences such as PACS 2006, Healthcare Information Management Systems Society 2006, Society for Computer Applications in Radiology 2006, and American Medical Informatics Association AMIA 2005 in October. They should plan site visits to see a system in use and keep current with the latest information through society and technology Web sites.

Although not essential, many orthopedists find it easier to use one vendor for all of their PACS components. Longevity in the industry and financial viability are important qualities to look for in a vendor, along with training and 24/7 technical support and maintenance. Physician training is a key factor to success, and it needs to happen before, during, and after implementation. Everyone who uses the PACS needs to be trained, but if this is not feasible, implementers can choose a physician or staff member who can train the trainers and be a liaison with the vendor.

Before purchasing a PACS, orthopedists should check that it requires user IDs to ensure that only authorized viewers access the images in compliance with Health Insurance Portability and Accountability Act regulations and has firewall security to deter viruses. The software and equipment should be Digital Imaging and Communications in Medicine compliant. The DICOM standard is a set of rules to allow the seamless exchange of medical images from one machine to another, especially if they are from different vendors. This standard is similar to Health Level 7 (HL7) standards for interoperability between health information technology systems.

The conversion to digital imaging does not happen overnight. A few orthopedists choose to digitize all or part of existing film libraries, which can be labor- and cost-intensive, while others opt to digitize as they go.

Cost can be an issue with digital imaging conversion, but for many orthopedists, it is not their number one priority, according to some vendors. There will be substantial upfront costs, along with yearly software license fees, but these are generally offset by the discontinued use of conventional x-rays, according to Alexander.

Physicians may also explore the impact PACS may have on efficiency, workflow, and productivity.

Determining where efficiency can be improved involves examining the amount of time saved and how quickly the system works. Another consideration when evaluating a PACS, therefore, is bandwidth or the transfer rate. Bandwidth is a measure of how much data can be transmitted in a certain amount of time (usually 1 second) and is usually referred to as kilobits per second (Kbps) or megabits per second (Mbps). Imaging files can be extremely large, as more and more include 3D rendering. To send these types of files quickly from one location to another requires a 5- or 10-Mb bandwidth.

PACS can offer tremendous advantages for orthopedists. Film, jackets, and labels become things of the past, along with expenses associated with hard-copy film developing, handling, processing, storage, retrieval, and disposal. Fewer retakes are required due to poor image quality, since PACS software allows for image enhancing. Duplication costs are eliminated as images are no longer lost or retaken, thus lowering patient radiation exposure. As long as they have the patient ID number on hand, multiple viewers can see copies of the original digital images immediately on different monitors in separate locations, even offsite through dedicated networks or the Internet.

"Filmless radiology and PACS are here to stay," Alexander said. "By learning the basics of PACS and filmless radiology, fear of the unknown and resistance to learning something new can be abated and orthopedists can begin to see the obvious value in switching."