Experience with Image Management Networks at Three Universities: Is the Cup Half-empty or Half-full?

A good evaluation study requires a good baseline study. Significant amounts of effort were directed toward determining existing problems in radiology image management. The baseline study is useful in two ways: the definition of problems that digital technology should address and the evaluation of the effectiveness of digital solutions. 2.1 Clinical Perspective The clinical issues of image management can be viewed either from the perspective of the “core” radiology service or from that of the referring physician. The “core” functions of radiology are performing examinations, reviewing the resulting images, consulting, and generating and distributing reports. Poor performance of any task connected with these functions will lead to poor service. The hospital or referring physician must consider broader issues than those considered by the radiologist. Examples of such issues include the questions of what demands a physician makes on the radiologist and how such demands can be successfully addressed. Similarly, a physician may ask the radiologist if there is an imaging technique which can help in patient diagnosis. This dialogue defines the consultation phase—the two physicians talking is one of the most important interfaces between the radiology department and the rest of the hospital operations. After talking to the radiologist and deciding that a procedure needs to be done, the next step is to schedule the procedure, which involves the use of an HIS/RIS. This initiates the core radiology service (mentioned above), which starts when the radiologist performs the procedure. Next a diagnosis is made and reports are generated by a radiologist. The referring physician reviews the report and films and often speaks with the radiologist again, involving interaction both with people and the electronic systems. From a clinical perspective, there are several potential problems in the film-based environment which result in poor service. First, a delay may occur in scheduling an examination. Once an examination has been completed, several factors may delay or adversely affect the quality of the report. These include both delays in accessing either current films or older images and missing previous studies. Since a single sheet of film cannot be in two places at once, the availability of films currently in use is also problematic. This is potentially more important when multimodality comparisons are required. Finally, the current workload on a radiologist may affect report generation time. Delays in getting radiologic procedures and reports completed can result in delays in patient care, and, if the referring physicians become too frustrated by such delays, the radiologist’s professional role may be affected. Improvements in radiology service can have a positive impact in patient care which in turn makes the radiology service that much more effective. Non-problem A number of problem areas have been identified in our study. There is however an important non-problem area that may become an issue in the digital environment. The image quality in current systems has been perfected over the past century and it is not a problem in current film-based systems. Furthermore the medical/legal issues are well-defined in this environment. 2.2 Operational Perspective A number of problems exists in the operations of radiology service because the image media is film. A digital imaging network should be viewed as a device to solve significant film-based operational problems that impact radiology service. Unavailable Films During a baseline study at Georgetown University Hospital in 1987 we found that 9% of films were unavailable when requested. The reasons for this are that they may be in another department or signed out for multimodality correlation, used for educational and research activities, in transit, misfiled on shelves, misfiled in the wrong jacket, given away, or stolen. Some of these problems are virtually impossible to resolve (e.g., misfiling in the wrong jacket, given away) in a film-based service. Misuse of Resources Unavailable films cause a loss of productivity among radiologists, the clerical staff, the technical staff, and referring physicians and their staffs. Unavailable films also cause misuse of expendable supplies such as film and chemicals, and misuse of the equipment resources used in film duplication. Report Generation When a diagnosis requires a multimodality correlation study, reporting is often delayed due to difficulties in collecting related images from various imaging systems. This creates a delay between the completion of a procedure and reading. Space One solution to the problem of missing files is to duplicate film files, thereby increasing space requirements. Also, the report process is frequently hindered by the unavailability of films, so the match-up of reports and films is incomplete, forcing the duplication of files in many departments. Cost Conventional radiology department operating costs impacted by DINS are detailed in Table 2. These figures are based upon a 300 bed institution which does approximately 80,000 to 100,000 procedures per year. Table 2 Table 2. Archive Materials $460k-720k Labor $1680k-2400k Maintenance $600k-1000k Depreciation $1000k-1500k Space (opportunity) $50k-100k Total $3790k-6720k Acquisition costs for equipment in a conventional department, including film handling equipment, the file room, and silver recovery equipment, is approximately $900,000.