Charles W. Gervais, MD

It has been more than 10 years since the development of diagnostic-quality, high-resolution digital imaging, yet this technology has not filtered down to community-based outpatient radiology practices or small hospitals. Why?

The two major reasons have been high start-up cost and the technical difficulties of managing the thousands of relatively large (1-12 MB) digital imaging computer files.

In November 1999, after careful research into all aspects of digital imaging and picture archiving and communications systems (PACS), Essex X-Ray, Ultrasound, and Mammography went digital, and we have never looked back. Essex is a full-service, community-based provider of outpatient imaging services operating 6 days per week and providing general radiography, fluoroscopic services, general and vascular ultrasound, and digital (computed radiography) mammography at four locations, all linked by a high-speed wide area network (WAN) using DSL modems and a sophisticated web server. These acute care "walk in" facilities augment Windsor's overcrowded hospital emergency departments and have become increasingly important since the closure of two Windsor acute care hospitals. In this community and province, there is a trend toward an increased emphasis on acute (non-life threatening) as well as routine outpatient care within private independent health facility (IHF).

We operate a high-speed (100 MB/sec), NT/LINUX-based LAN/WAN, with three peripheral offices networked with a main office providing real-time enterprisewide RIS integration. The network servers facilitate the transfer of the digital CR (computed radiography) and gastrointestinal images and the capture and digital storage of all ultrasound images. After integration into the PACS database, images are routed automatically for radiologist review on the primary radiologist's workstation, then archived on dedicated 1 TB storage servers.

Digital image radiologist review and reporting is performed on dual ultra-high resolution 5 million pixel monochrome imaging monitors. Workflow management incorporating radiologist worklist, modality worklist, digital dictation, voice recognition software, and an integrated web-based image server for remote 24/7 access to our image database via Regional HealthNet, our web portal, are all incorporated into this radiology practice.

At Essex X-Ray, all digital mammographic patient information is also kept in a relational database using custom software designed to facilitate efficient patient management, and pathology follow-up/and research. This system also generates important patient "follow-up reminder care and request for pathology report letters" to referring physicians and maintains the detailed "teaching file" and  pathology follow-up list.

The current high-speed LAN/WAN, data management system, high (2 x 2.5 K) resolution review station, network, and storage facilities are ideal for CR image management in this busy general radiology practice.

The Micro PACS Project

In order for Essex X-ray to successfully implement high-resolution CR digital imaging, many cost and technical problems had to be solved. This custom solution for the first time in Canada allows a small/medium-sized IHF facility such as ours to serve as a model for digital conversion for private outpatient IHF facilities across North America.

The advantages of digital/filmless radiology are obvious: superior images; reduced total patient x-ray exposures; no air or water pollution and no chemicals; no lost films; no x-ray storage vaults/delays in retrieving films from off-site storage; digital images really can be in more than one place at a time; increased patient care efficiency/throughput; and reduced waiting times.

The reality is that it is becoming a digital world. Soon, most hospitals and medical professionals will be online or at least have easy access to the Internet.

Physicians may request access to the Essex X-Ray, Ultrasound, and Mammography Radiology Image Server through our web site http://www.xray.ca/ and will be given access to our secure web server in order to directly view their patients' images from their office/home or anywhere in the world. All that physicians require is a secure password, the patient's unique identifier number, and access to the web.

Without web access, physicians may view high-resolution DICOM images directly on any Windows computer via CD or receive low-resolution digital photographs on paper and keep these for their records.

Live teleradiology conferencing is now possible by simply retrieving patient films via the Internet secure server, then calling to speak with the Essex X-Ray radiologist to discuss the case.

We believe that high-resolution CR technology and high-resolution review stations are ideal for screening and diagnostic mammography, particularly in patients with radiographically dense breasts. This belief is not universally held within the Canadian and American mammographic communities. However, these attitudes are rapidly changing as major Toronto and Montreal teaching hospitals, including the Princess Margaret Cancer Hospital, adopt digital mammography as the new standard for patient care.

The significant potential reduction in patient dose, high resolution, and increased image latitude without loss of contrast are the primary reasons for our position.

SHOULD YOU CONVERT?

The essence of this PACS project was to determine whether it is feasible to address both the cost and technical factors using state-of-the-art CR technology and PACS software in our small/medium-sized community outpatient radiology facility.

Cost factors include the initial expense for digital image capture technology (presently limited to CR or DR), the cost of high-resolution review, quality control, and administrative workstations, and the cost of medium- and long-term digital data storage.

By implementing computed radiography and digital (CR) mammography, Essex X-Ray, Ultrasound and Mammography reduced films costs, thereby enabling a 2.2-year return on the PACS investment.

Technical factors that have prevented the adoption of this technology by radiologists/hospitals/clinics include the variety of digital imaging formats (to some extent standardized as DICOM), the integration of existing HIS/RIS systems with image capture devices/image review software, the absence of a sufficiently robust open database connectivity (ODBC)-compliant database software to allow for ongoing management and integration of patient information with large numbers of images from multiple visits, and generalized reluctance to accept and work with digitized images.

Thanks largely to the development of powerful, inexpensive personal computers and a dramatic drop in the cost of digital imaging storage, now is the time to go digital in your private office or small hospital. We anticipated a 4.8-year break-even point, but achieved that goal in 2.2 years based on savings on film/storage costs and more efficient use of staff.

Here are some suggestions for those interested in pursuing a digital practice:

Do not be afraid to select your own hardware and enterprise configuration. Multi-modality DICOM integration is not as difficult as it once was. Get the best workstations, monitors, and servers you can even though they will be nearly obsolete in 4 years.

Select CR technology. CR allows full use of existing standard x-ray and mammography equipment, reducing start-up costs and operating costs every year. There are several very good CR manufacturers presently. Pick one that provides at least a 5-year, full-service contract ensuring virtually 100% uptime. If their equipment is reliable, the costs should not exceed 7% per year.

Pick a solid PACS vendor. The right PACS will make you a digital hero while the wrong PACS will result in staff mutiny and summary execution by your board of directors. Choose a PACS vendor with a proven commitment to service and product development as technology changes. This is the most important decision you will make.

IN SUMMARY

Like many radiologists and imaging clinics, we had been impatiently awaiting the digital panacea. Until recent developments in digital acquisition, data storage, and reductions in high-speed workstation costs, this was like dancing with a hologram. The multifaceted PACS/imaging software to receive, review, store, and keep track of all of these patient images just was not available to front-line radiologists working in community-based clinics like ours. We are now demonstrating that this is all possible. Our 1999 decision to "go digital" is providing a significant improvement to patient care in Essex County, Canada.

Charles W. Gervais, MD, consultant radiologist, Essex X-Ray, Ultrasound and Mammography, Windsor, Amherstburg, and Tecumseh, Ontario, www.xray.ca.