DR Done the Right Way

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If service, patient safety, and profit weren’t incentives enough, now hospitals and imaging clinics have another inducement to go digital: the Obama administration’s federal health care stimulus plan, which stresses health care IT and electronic medical records. Steven Mendelsohn, MD, says, “The only choice to make is whether you go with DR or CR. Still using film makes no sense.” Mendelsohn is medical director of Zwanger-Pesiri Radiology, which operates eight imaging clinics in Long Island, New York. Deciding where to put DR and when to use CR depends on the practice and needs to be analyzed, Mendelsohn adds. “There is no one solution,” he says.
imageSteven Mendelsohn, MD
To make a long history short, CR preceded DR as a way to capture x-rays electronically, but CR uses a removable-plate image-capture system that is a lot like film-based radiography in that a plate must be transported to a reader, where it can be made into an image. DR, on the other hand, contains the image receptor permanently embedded inside the table or wall-mounted surface against which the patient lies or stands. With DR, the image is available on a monitor in the radiography room within seconds, and the technologist can verify it and send it to PACS from the radiography room itself. Because DR allows the technologist to stay right in the room with the patient, both speed and patient safety are enhanced. Instead taking x-ray plates or CR cassettes outside the room to be fed into an x-ray processor or CR reader, the technologist can remain with the patient and will know almost immediately whether the image was acquired correctly. Nonetheless, CR has its place, and any hospital or clinic should do its homework on where and how CR might be deployed, as Mendelsohn suggests. Weighing the Advantages Mendelsohn says that Zwanger-Pesiri experimented with both CR and DR in different offices, finding that CR was twice as fast as film and that DR was twice as fast as CR, making DR four times faster than film. Mendelsohn stresses that this is a seat-of-the-pants assessment because conditions, patients, and technologists vary so much. “It’s hard to give a real number,” he says. Getting radiography digitized so that it can go on PACS and become part of the electronic medical record is not for the financially faint of heart, although in the long run, savings on film, film rooms, and film staff; workflow efficiencies; and referrer goodwill probably offset outlays for DR and CR. Price is certainly a factor to consider in deploying DR technology. Facilities should strategically examine their workflow patterns and caseloads to determine whether CR or DR would constitute the more cost-effective route to digital imaging. Statistics on the long-term costs of equipment ownership and on the equipment's service history (and costs) should also be examined. Both CR and DR offer improvements in workflow, cost savings on consumables, and reduced staffing requirements. One strategy for DR deployment is to do it first, before competitors do. That’s what Zwanger-Pesiri Radiology did with its eight clinics. Back in the mid-1990s, when Zwanger-Pesiri began to move away from film, it was a leader. “We were very early with DR in two offices, then we had CR in two offices, and subsequently, we went with DR in the next four,” Mendelsohn says. “We have DR now at all our sites; we have CR in four.” Initially, Mendelsohn says, Zwanger-Pesiri put DR in the two clinics that were its busiest and CR in the two where the patient volume was lowest. Later, it added the Unity SpeedSuite DR system from Fujifilm America Medical Systems, Stamford, Conn, at other sites, and it now uses CR at some sites principally for fluoroscopy, gastrointestinal and barium-enema studies, and patient overflow from any bottlenecked DR rooms. “A fully digital fluoroscopy unit is very expensive, and this way, we can do it less expensively by using CR,” he adds. When it initially installed the Fujifilm DR system at its busiest site, Mendelsohn says, Zwanger-Pesiri was able to downsize from five radiography rooms to one, plus a fluoroscopy room with CR. “We are doing two, three, or four times the volume with only two rooms, instead of five,” he says. “It gave us a lot more real estate.” For a time, Zwanger-Pesiri used one former radiography room for CT, but it has now converted all three to ultrasound, Mendelsohn adds. “DR enables us to perform studies much more quickly,” he says. “The technologist can repeat any images where the patient is not optimally positioned. The technologist can postprocess overpenetrated or underpenetrated studies to make them usable, so there’s no added radiation delivered to the patient. As soon as the technologist is finished with the views, the patient walks out, and the next patient comes in,” Mendelsohn says. The actual imaging time for each patient with DR is only five or ten seconds, compared to the 90 seconds or so that it took the technologist to image the same patient using film. PACS Efficiencies Tracking each patient is also easy. “The Fujifilm DR workstations have the modality worklists, and the patient demographics from the RIS are brought directly across from the modality to the DR workstation. Then, the images go to PACS,” Mendelsohn says. It’s a tight circle in which patient identifiers never get confused, so images never get attached to the wrong patient’s record. Another huge advantage of DR is that once the images are on the PACS, they can be read by any of the Zwanger-Pesiri radiologists who interpret radiographs. Therefore, Mendelsohn says, he’s been able to place most of his radiography specialists in one or two clinics and let them read images from the other six. “It’s greatly improved our subspecialization,” he says. “It’s enabled me to hire subspecialists in each area. I don’t need to double up and have CT specialists read radiographs.” DR has also allowed Zwanger-Pesiri to offer early-morning and late-evening radiography to patients in all its clinics, with minimal staffing by radiologists. All the group’s clinics are hooked together on the same PACS, and a radiologist coming in early or staying late can read from any location, Mendelsohn notes. One decision that Zwanger-Pesiri made with DR was to deploy Fujifilm's Unity SpeedSuite U-arm detectors at most locations, while using teamed wall-mounted and table configurations at only one site. “The U-arm is a lot more efficient for the technologist and offers a great deal of flexibility to address a wide range of cases,” Mendelsohn says. Zwanger-Pesiri is also using some portable detectors that use radiofrequency transmission to send images to master detectors, he adds. Another huge impact of DR, Mendelsohn says, has been the turnaround time from image capture to the finished radiologist’s report. It can now be as little as five to ten minutes, Mendelsohn says. Because physician referrals come throughout the day, Zwanger-Pesiri takes all its radiography patients on a walk-in basis, but even if a clinic is busy, reports are usually done in 30 minutes or, at most, an hour. Mendelsohn says, “It depends on the volume, which is unpredictable for radiography.” Neither integration nor archiving has been a problem with DR; Mendelsohn says, “It’s just another Internet-protocol address and the acquisition unit.” As for archiving, storage has become so inexpensive that Zwanger-Pesiri never deletes any digital images. “We just add on six or eight terabytes every couple of months. We can see even a 10–year-old study in a matter of 10 or 15 seconds at any of our offices,” Mendelsohn says. As for the all-important return on investment, Mendelsohn says that he can’t quote a number, but he calls DR a no-brainer financially. “DR makes the process so much cheaper. It’s much more expensive not to have DR,” he says. George Wiley is a contributing writer for ImagingBiz.com.