Healthcare resources are primarily centralized in urban areas, creating increased competition among large institutions. At the same time, third-party payers continue to pressure hospital administrators to redouble their cost containment efforts.

Teleradiology can provide important diagnostic services to patients in outlying areas and, at the same time, increase the productivity of highly skilled professionals in urban medical centers. With teleradiology, diagnostic images are digitized and transmitted electronically from distant medical facilities that cannot afford a staff radiologist to a major medical center with staff radiologists.

Baptist Hospital in Nashville, Tenn., offers a good example of how teleradiology benefits both the central hospital and the patients being served by outlying medical facilities.

An immense and impressive complex with nearly 1,000 physicians on staff and 759 beds, Baptist Hospital spans a 7-block area near downtown Nashville. The not-for-profit hospital's primary service area covers seven counties in middle Tennessee via Baptist's remote-site network, which consists of three different types of medical facilities:

•Baptist Centra-Care Centers, which require no appointments and focus on patients with minor injuries or illnesses who have no primary care physician. There are 14 of these centers currently in operation.

•Occupational medicine centers provide therapeutic and rehabilitation services to patients who are recovering from more serious conditions. Four of these centers are in operation.

•Baptist Health Care Group consists of about 60 physicians in Baptist-owned medical practices which serve patients from several medical buildings located around the greater Nashville area.

•Baptist Bellevue Medical Center, located approximately 15 miles west of Baptist Hospital, houses a number of primary care physicians and pediatricians. It was also the site of a Baptist Centra-Care walk-in clinic until recently. As a result, the radiology department at Bellevue is one of our busiest remote sites. It was, therefore, the logical choice for the teleradiology pilot program initiated by Tom McBrayer at Baptist Hospital in mid-1995.

Approximately 20 percent of the patients who receive radiologic exams at pilot sites require immediate readings. Before the teleradiology system became operational, those patients had to be referred elsewhere.

Teleradiology has also offered monitary and efficiency gains to Baptist Hospital. Couriers no longer are required to make film pickups at remote sites twice a day. The films generated daily from Bellevue no longer are hung on viewboxes and alternators at Baptist Hospital for interpretation. An hour of a technologist's time each day, which used to be dedicated to hanging and removing these films, is now devoted to more productive tasks. Making diagnoses on softcopy displays also has helped the radiologists improve their efficiency.

Finally, the time savings resulting from the teleradiology service is motivating private physicians who are not part of the Baptist network to refer their patients to Bellevue. The system eliminates the chance for films to be misrouted when they reach the hospital, which results in lost time and, sometimes, in the need to repeat the exam.

How the system works

In selecting the teleradiology system for Baptist Hospital, one factor overshadowed all others: image resolution. Unless radiologists are confident they are able to make accurate interpretations from images on the monitor, the advantages we look for from a system are lost. Image resolution is, therefore, of prime importance.

We considered four different teleradiology systems and discovered there is a direct, almost one-to-one correlation between price and image resolution and transmission times. Baptist Hospital chose the Kodak Digital ScienceTM medical imaging system, which offers a 2K ¥ 2.5K-pixel maximum resolution, coming very close to reproducing the clarity of the original film image.

The film is fed into the film digitizer. Up to six 14 ¥ 17-inch images can be fed into the digitizer automatically. It takes about one minute to create each 10-megabyte digital image file, which is downloaded to the computer's memory.

Images are then viewed on a review workstation. If necessary, the workstation controls can be used to enhance the images' contrast and density to optimize readability before transmitting them to the radiology department at Baptist Hospital. The transmission time for each image, over T1 telephone lines, is approximately one minute from Bellevue.

At the receiving end, Baptist Hospital is equipped with a high-resolution two-monitor personal display system (PDS) workstation. The monitors offer a maximum image brightness that is five times that of an ordinary computer monitor.

The side-by-side monitors enable Baptist's radiologists to compare images of the same patient taken at different times. The entire image can be viewed, or the radiologist can zoom in on areas of particular diagnostic interest.

Radiologists at Baptist Hospital make all interpretations from images on the workstation; however, images also can be transmitted to a networked laser printer for output on film.

Additionally, the radiology department at Baptist Hospital uses a digital dictation system which makes it possible for remote sites to access the radiologist's report via any touch-tone phone. The report also is transmitted over telephone lines to a commercial transcription service company which keys the report and transmits it to the computer system at the hospital. The radiologist signs off on the report electronically and the system automatically faxes a copy of the report to the office of the physician who requested the radiograph.

Future plans

We consider the teleradiology pilot program to be an unqualified success. We measure this success by the willingness of our radiologists to use the system; they are making primary diagnoses from images on the monitor, and everyone concerned is enthusiastic about the technology and the results.

We are anxious to try to apply digital imaging technology to the reading of MRI and CT scans. We now spend $250,000 per year for film for MRI and CT scans. This information can be archived on a DAT disk or magnetic tape. Normally, images are transmitted and interpreted, and are then output to film and placed with the report in the patient's folder. But, if we can convince doctors to read scans as well as x-ray images from monitors-selecting only the part of the image that shows what the diagnosis was based on-we can project a 50 percent savings in what we spend annually on film.

When all is said and done, patients benefit as much as medical facilities from the adoption of digital imaging. First, treatment can begin sooner because diagnoses can be obtained faster. Being able to digitally enhance film images can often result in the reduction of repeat imaging procedures. Finally, teleradiology systems permit hospitals to provide more services to more patients without increasing the number of employees. Ultimately, this helps to contain the cost of health care for everyone. AR

Ms. Tucker is Director of Medical Imaging at Baptist Hospital in Nashville, TN.