SAN JOSE MEDICAL CNETER, at the southern tip of California's Silicon Valley, admits more victims of serious accidents and assaults than any other nearby hospital. Accordingly, the 328-bed, level II trauma facility's emergency department (ED)the front line of care for these patientsis a place where high-stakes medical decision-making depends heavily on ready access to good, clear radiographic images.

Previously, the ED's most often-used imaging modality for that purpose was plain-film x-ray. Today, it is CR, which the hospital installed in November 2001.

"Our overarching reason for adding CR to the emergency department was to eliminate the problem of films that, for whatever reason, were unavailable when ED physicians wanted to look at them," says William Morse, RT, director of diagnostic imaging. "In the days when x-ray was our primary ED imaging modality, it seemed almost inevitable that a certain percentage of films would be unavailable upon request. Either the films would be in the possession of someone else, or they would just be unaccounted for."

Because CR is a digital modality, images can be displayed in soft-copy mode wherever there is a networked monitor throughout the health care enterprise.

"The vast majority of accesses to images acquired in the ED using CR are now done in soft-copy mode," says Morse. "Thanks to CR, the images the various users want to see are always available to them and always within seconds of making the request. Physician satisfaction has soared as a result. It's also increased their ability to provide quality care by permitting care decisions to be made earlier, which contributes as well to a reduction in the need for consumption of hospital resources."

That is important at San Jose Medical Center, located in the heart of the city of San Jose, fourth largest metropolis in the state, where dramatic population growth over the last two decades has translated into a massive increase in demand for hospital services, the emergency department in particular. Compounding the problem, San Jose Medical Center has been grappling with rising operational costs amid declining reimbursements, according to Morse.

Emergency department CR helps with this not only by giving physicians a tool to indirectly conserve resources but by enabling radiology technologists to be more efficient andby extensionmore productive.

"The biggest obstacle to technologist's productivity in the ED environment was the high rate of repeat imaging due to problems they would encounter with the positioning of the patients," says Morse. "With plain film, you shoot the image and that's it, you're stuck with it. You have no other option than to repeat the shot if the film came out subpar. But with CR, the technologists gain substantial flexibility in the processing of images so that most of those that before would have been discarded as being of unacceptable quality can now be electronically fine-tuned and brought up to par. For that reason, the technologists are far less likely to need to go back and repeat an image."

NO PACS IN PICTURE YET

The CR in San Jose Medical Center's ED currently is the only such system on campus. Technically speaking, though, the device is not actually in the ED. More properly; it is situated a short distance down the corridor from the ED.

"We've put the CR in a room next door to where we have our ED-dedicated x-ray machines and a CT scanner," says Morse. "This is also where we perform the processing and outputting of images from those three modalities. We've adopted this arrangement because it allows us to have the acquisition devices and processors and imagers all in one central place, which saves the technologists some wear-and-tear on their feet."

Images acquired via CR are shot using the same techniques involved in taking x-ray images, Morse indicates. However, the similarities end there. First, acquired CR images are captured on a plate built into a removable cassette. Then, when shooting is completed, the technologist takes the cassette from the CR and loads it into a laser-fired reader in the processing room. The reader translates the plate-bound image to a data stream, which is organized by computer into a digital file. From there, the file is relayed to a nearby view station, connected to the reader by cable.

The images also are transmitted over a localized network that links both the CR reader and the view station adjacent to the ground-floor east-wing ED to the main radiology department on the hospital's second floor west wing (home to an array of imaging services that include nuclear medicine, CT, MRI, general diagnostics, special procedures, ultrasound, noninvasive vascular laboratory, and mammography) for interpretation by a radiologist.

"The network is built on a 10-baseT fiber-optic backbone with two communications closets containing 10-gigabit switched Ethernet routers each," Morse explains. "To that backbone and through an intranet web viewer arrangement, we've connected two workstations in the main radiology department. Recently, we installed view stations in the ICU, TCU, and other key units around the hospital."

Morse describes the intranet web-viewer as essentially a database maintained physically in the radiology department. All CR output, plus the images from other digital modalities, is immediately sent to this database for archival purposes.

"We have no long-term storage capability associated with this databasewe store only about 30 days' worth of work, and film is still printed for permanent filing," he says. "We currently are looking at increasing our database to longterm storage and moving to implement a PACS, which, for us, is probably another year or two down the road."

Not having a PACS also limits the extent to which CR images from the ED can be distributed, Morse laments.

"But CR is at least giving the physicians in the ED accessibility they didn't have before," he assures.

On Again, Off Again

The installation of CR at San Jose Medical Center came about as a result of plans the hospital formulated to remodel its ED and upgrade the equipment deployed there. Planning began in 1998. However, there was hesitancy on the part of top administrators to sign off on the plan and include it in the budget.

"The hospital wanted to make sure we got not only the best possible equipment to suit the requirements of the ED environment, but also the most attractive pricing and terms," says Morse.

To obtain approval for the acquisition of CR in lieu of plain film x-ray entailed first convincing the hospital's CFO and CEO that such a purchase had meritwhich turned out to be not as difficult a sell as Morse feared. Once that hurdle was cleared, a formal proposal was prepared for consideration by the regional administrators of HCA. Liking what they read, the regional decision-makers gave the proposal their stamp of approval and sent it along to national headquarters for a final OK.

The only condition imposed by HCA in granting permission for the purchase was that San Jose Medical Center's radiology department had to shop for a CR from among HCA's preferred vendors.

Morse's main worry during installation of that CR system was whether he could convince Agfa and the vendor providing the network equipment to work in a cohesive partnership. Happily, Agfa readily agreed to cooperate fully with the network vendor, and a similar pledge was obtained from the network vendor with regard to its dealings with Agfa, Morse confides.

"This partnership between the vendors was essential in order to ensure that there would be fluent exchanges of text and image files along and across the nodes of the network," says Morse. "What we did was insist that the vendors sit down for a joint meeting with us so we could map out the steps we needed to take in order to achieve this desired level of connectivity. We also made sure that each party knew exactly what their responsibilities in this effort were going to be so that, in the event that problems arose during installation and testing, there would be no finger-pointing and attempts by the vendors to fix blame on the other guy."

The vendors, in fact, had worked together many times before. "Because of this relationship between the vendors," says Morse, "a lot of the bugs that might have arisen during installation were worked out before we ever began."

CHANGED WORKFLOW

Interestingly, the one player that benefited most from the sit-down meetings between the hospital and the vendors was San Jose Medical Center's information services (IS) department. The IS team came to the meetings thoroughly versed in the building of networks, but possessed only a vague appreciation of the highly specific networking needs of the radiology department.

"The meetings presented an opportunity for IS to get to better know radiology and what we wanted to see happen when diagnostic quality images were moved from one node of the network to another, why we needed an image sent to one area but not another, why we wanted multiple redundancies in our systems, and so forth," Morse says.

Before long, the IS department was knowledgeable enough about radiology's needs to be able to intervene directly with the vendors when network-related problems affecting the radiology department arose. And, likewise, the radiology department became informed enough about networks and their operation to be able to assume primary responsibility for managing the network once it was implemented.

"The IS department helps us troubleshoot the network, but it's the radiology department that manages it on a day-to-day basis," says Morse.

Morse reports that it took about 4 hours to provide basic training in use of the CR system to each of the ED-assigned technologists.

"We trained the technologists in small groups rather than one at a time in order to be more efficient about it," he says. "Training included a rundown of the ways in which CR was different from the x-ray equipment they were familiar with, how to avoid problems when using the equipment, and which techniques to use under what circumstances."

Training was also provided to the radiologists and ED physicians on use of the review stations and how to understandand appreciatethe nuances of CR images.

"CR provides more detail than what you get from traditional x-ray," says Morse. "Many physicians, when they see a CR image for the first time, become a bit confused by what's there, so training is important to quickly get them comfortable with that deeper detail."

With CR came several changes in workflow, the most significant of which involved the processing of images.

"Instead of flashing the film and then going into a darkroom to process it, the technologist was now being asked to perform processing tasks on a computer keyboard," says Morse. "To our surprise, this change slowed things down. The reason was that, while CR is a computerized way of doing things, some of our technologists did not have sufficient computer skills to be able to quickly perform the necessary keyboard tasks, such as entering patient demographic information."

The radiology department is attempting to remedy this shortcoming by training technologist assistants to assume responsibility for the data entry piece of the CR imaging-and-processing operation. The ideal solution, of course, would be to interface the CR system with the department's long-ago installed radiology information system (RIS), wherein patient demographic information already resides. However, Morse reveals, a RIS-CR interface was purchased, but, due to concerns about security stemming from provisions of the federal Health Insurance Portability and Accountability Act, has not been implemented.

"We actually purchased a RIS broker to permit the interface with our CR," he says. "However, HCA is requiring that before we can utilize it, the vendor must sign a security agreement, the language of which is currently the subject of extensive negotiation. The agreement is intended to clarify how the confidentiality of information will be protected whenever the vendor remotely dials into our system to perform maintenance tasks or troubleshoot. It also is intended to spell out exactly who bears responsibility under what circumstances in the event unauthorized access to that confidential information occurs via a link from the vendor. It could be quite a while before all of this is thrashed out."

Meanwhile, the next step for San Jose Medical Center is to install a CR image-acquisition system in the main radiology department. This, says Morse, will enable more radiology customers around the hospital to gain the same benefits currently enjoyed by the ED department.

"CR is proving an excellent addition to our hospital," he says. "For us, the ED was the right place to begin implementing it. It gave us an excellent foundation to build upon and the experience necessary to make future deployments proceed much more smoothly." b

Rich Smith is a contributing writer for Decisions in Imaging Economics.