Digital imaging has assumed a primary role at our institution with the recent implementation of a computed radiography (CR) system that we believe improves the diagnostic quality of the images and speeds distribution of radiology reports.

The University of Texas Medical Branch at Galveston (UTMB) is a 950-bed facility that performs 250,000 radiology procedures throughout the hospital system each year. The department of radiology routinely performs 600 to 800 studies per day.

The first phase of the CR project had a clear mission: to develop a system that could handle the workload of the ER and outlying clinics, while reducing the potential for lost films. Kodak's Health Imaging division joined us in developing a pilot program by putting their CR technology products to the test.

This test program set the groundwork for instituting an imaging system with an eye toward long-term cost reductions and increased productivity. Our immediate goal was to improve efficiency and eliminate lost films. Our ultimate goal is to gradually expand the current project and integrate other digital modalities, such as MRI and CT, and implement digital viewing and a central archive to store and retrieve these images. Because the planned medical viewing stations support DICOM 3.0, we expect to network and view all digital modalities on these workstations.

Distinct digital advantage

Digital imaging offers distinct advantages over traditional radiography. Digital images are processed and sent over a local area network to a diagnostic workstation. Radiologists analyze the displayed image and send their report, along with the image, to pertinent departments. The digital workflow eliminates the need to physically move film images, reducing transport and processing time from hours to seconds. Studies cannot be misplaced or misfiled because they are stored digitally.

When the Kodak Digital ScienceTM computed radiology system 400 came on line in our ER, the lost or unreadable film rate dropped from 57% to 2%. The CR system also allows a wider contrast range than radiographic film. This expanded exposure range reduces the need for repeats due to improper technique or other variables. Clinicians can access the images as a soft copy on their review workstations and their reports on the radiology information systems (RIS) monitors.

Expanded network

The initial success we experienced with our digital imaging system paved the way for phase two: expanding the network to cover the entire hospital complex and other outpatient facilities.

As we expanded the application of the CR system, we institutionalized the project, forming a team comprised of representatives from the hospital administration, the radiology department, physicians from multiple departments, clinicians, information services, and our local area network administrators. Additionally, the manufacturer became an integral part of that team and worked closely with us to match our needs with appropriate technologies.

Through regular meetings, a clear understanding of the requirements of each department was established. Our motto became "tell me what we can do to make this work." We decided to put the system on an isolated network. Compatibility issues for the capture devices in the different areas of the hospital were worked out.

With the decentralization of the department and the new remote sites, the CR system began to show its value in alleviating demands on personnel

and reducing turnaround time. These days radiologists, working at diagnostic workstations, can support the needs of multiple clinics without having to travel to each site.

Within the UTMB complex in Galveston, turnaround times for reports have decreased dramatically-in some cases, from weeks to hours. At the first outpatient facility, the radiologist's report is often delivered to the requesting doctor within 15 to 30 minutes, utilizing CR, MedSpeak, and IDXRAD.

The most recent site about to join our system is the primary care outpatient clinic (PCOC). The PCOC is located 20 miles from Galveston, in Texas City. Previously, a courier service was used to collect and deliver film studies. It could easily take a day or more for physicians to receive a report. Now, the image can be read, analyzed and returned within minutes.

In the near future, we will be expanding our CR system to include 10 additional workstations to support our affiliation with the Texas Department of Criminal Justice (TDCJ). Currently, inmates from all over the state have to be transported to UTMB for radiology needs. When the computed radiography system is fully operational, these inmates will be examined at remote sites, and their images can be captured and transmitted electronically to us for professional analysis. This telemedicine system will reduce the need and the expense of transporting inmates and film studies.

Improvements in patient care

Traditionally, the only way to augment viewing a radiographic film image was with a hotlight or occasionally a magnifying glass. Using the imaging software available today, radiologists are able to manipulate the brightness and contrast of the image, reverse the image, and use a virtual "magnifying glass" with varying powers of magnification to enhance the image and increase their ability to make an accurate diagnosis.

Initially there was concern that the workstations would not have sufficient resolution needed to view hairline fractures and minutia. However, improvements in diagnostic-level monitors have quelled these concerns. In fact, radiologists report that the high-resolution diagnostic monitors (and the system's sophisticated processing software) allow them to detect subtle details both in bone and soft tissue.

Training was available during the implementation phase of the system, and taking advantage of this option helped our radiologists and technologists apply the equipment to its full potential. Within a few weeks, radiologists were commenting on their success in finding injuries that would have been difficult or impossible to see on a traditional radiographic film image.

Digital archiving

Our next phase is to implement a digital archival system. Currently the archive consists of a library of traditional analog film records. Digital files are printed on film by laser printers and kept in a hard-copy format. However, when the computed radiography system is completely integrated, output of traditional hard copy studies will be eliminated, except for mammography. All current and future images will be stored in the digital archive, though existing film images will be continue to be maintained for appropriate time periods.

We anticipate an 80% reduction in consumables when we have converted to a digital imaging system, with projected savings of more than $1 million a year in related expenditures. The medical image and information library will be incorporated into the PACS system so that past studies can be accessed either through a workstation connected to the RIS or directly to the diagnostic workstations. When this system is on-line, diagnostic images will be readily available without the need for travel to a storage site.

Many of the savings are intangible at this point. However we have already improved efficiency of both physicians and technologists, reduced the labor and expense of repeat films and search time for missing films, and expedited visits for the patient.

Each phase of the CR system has brought with it an increase in efficiency that will ultimately result in significant cost savings. By instituting digital imaging technology, UTMB utilizes state-of-the-art radiology imaging to provide the highest quality of patient care while reducing costs and increasing efficiency. AR

Dr. Swischuk is Medical Director of Pediatric Radiology and Mr. Reyes is Director of Radiology Services at the University of Texas Medical Branch at Galveston in Galveston, TX.