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Physicians weigh the costs, benefits and challenges of digital imaging systems

Surgeons generally agree that digital imaging will eventually eliminateplain film to become the universal method.

Issue: July 2006

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Digital imaging is still not a universal tool in orthopedics, but more practices are recognizing its benefits and gradually implementing its technology despite some cost and reimbursement constraints.

Whether their practices have “gone digital” or not, most orthopedists now agree that plain X-ray film images will one day become obsolete. In the meantime, all are keeping an eye on the latest technology to prepare for the time when every office and hospital uses digital systems.

The following tells the experience of five orthopedic surgeons, all at different stages of “going digital” in their practices.

Tremendous cost savings

After using his digital imaging and picture archiving and communications system (PACS) for six months, Koco Eaton, MD, is smitten with the new tools. “To say I’ve been happy with the new system is an understatement,” Eaton, team physician for the Tampa Bay Devil Rays baseball team, told Orthopedics Today.

After a smooth implementation and simple training for his staff, Eaton’s one-man office is up and running, and his staff is reaping even more benefits than expected. Chart and X-ray retrieval are instantaneous from office or home, he said.

Eaton claims digital images offer more accuracy than traditional film images, and the switch to digital imaging has also saved him money. He’s eliminated large Xerox machines and the office space that housed those large machines.

“Now my office space gets used only for seeing patients,” he said. “I don’t have any office space going to [storing] medical records [or] X-rays.”

He also saves money on printing supplies, including paper and chemicals. Most importantly, Eaton’s overhead cost remained the same when he started his own practice, after leaving a five-man group that did not use digital imaging.

“This new system is paying for itself because my dollar cost has stayed about the same, but yet my utilization has gone up tremendously,” he said.

Still some problems

Not every digital user has had such a smooth ride. Peter R. Kurzweil, MD, of the Southern California Center for Sports Medicine in Long Beach, said his practice implemented a digital system for three reasons: technicians could increase productivity by one-third; patients’ radiation dosage is 30% to 50% lower with a digital system; and a digital unit offers better image quality with a larger “dynamic range.”

The system changed the way the physicians at Kurzweil’s center view X-rays. They can now easily scroll through MRI scans, as well as magnify, change contrast and rotate the images on the monitor.

“One can also easily measure angles or distances and template joints for arthroplasty,” Kurzweil told Orthopedics Today. “It reduces the need to repeat films due to poor angles or exposure, which not only saves time but also lowers radiation exposure for our patients.”

Despite these added benefits, Kurzweil said his practice experiences occasional downtime – although it’s usually quickly restored – as well as other minor annoyances, such as multiple log-ins.

There are also training issues. Only one X-ray technician at the clinic is familiar with the digital system. When he is out of the office, physicians resort to using the “old-fashioned” X-ray unit, Kurzweil said.

Another issue: “Currently, our system cannot interface with our hospital or surgery center,” Kurzweil said. “This means we either have to print or develop films from our digital images and bring them to the operating room. This can negate some of the cost savings of going filmless.”

Integrating with an EMR is key

Practices can take a number of different approaches when implementing digital technology. In many instances, integration with an electronic medical records (EMR) system is the most important consideration.

Summit Orthopedics Ltd., a 25-physician group with six offices in St. Paul, Minn., is currently implementing a digital system after seeing similar systems in use at community hospitals, said Paul D. Hartleben, MD, a spine surgeon at Summit.

The practice already implemented an EMR system, which Hartleben said puts them at an advantage. “You get to finally interface with electronics more, and I think there’s more benefit with an EMR [system] than there is with a PACS, but the two together is a full package,” he told Orthopedics Today.

Their positive experience with the EMR system was also instrumental in helping them choose a PACS and digital imaging vendor.

“In the end, we chose a PACS system that was fully integrated with our EMR,” Hartleben said. “The EMR company partnered with a PACS system, and they worked to [integrate the systems] prior to selling their products.”

Now, when the physicians view a patient’s information, clinical notes, work slips and X-rays are all available for viewing.

Although the quality of MRI scans has improved with certain monitors, Hartleben said he would prefer to view his spine X-rays on plain film. A lumbar X-ray in the operating room requires a high amount of radiation, super-sensitive film and grids and an experienced X-ray technician.

“To shoot that film in the same manner digitally is extremely difficult,” Hartleben said. “I think it’s because the digital film media are not as sensitive as some of the other film medias out there, and so the pictures are less quality.” Hospitals are currently working to resolve this issue, he added.

Many physicians have not implemented digital imaging or a PACS system because of practice size, financial reasons and convenience considerations.

James P. Tasto, MD, of San Diego and an Orthopedics Today editorial board member, and his three partners decided not to implement digital imaging because of the additional expense – something that most small practices find to be a problem.

“We continue to face reduced reimbursement and we continue to be exposed to an increasing amount of new technology,” Tasto told Orthopedics Today. “And the two are somewhat incompatible — to stay abreast of all the technological advances and still be able to afford them.”

The practice already implemented an EMR system, finding it necessary for billing and electronic submission requirements. However, the partners felt that the actual imaging gains of a digital imaging system were not worth the expense and time it took to implement such a system.

“We don’t want to be ahead of the curve on this particular investment,” Tasto said. “We’re beginning to notice a number of things that are problematic with it, and hopefully those will be solved by the time we decide to get into it.”

David A. Wong, MD, of the Denver Spine Center and an Orthopedics Today editorial board member, said his practice is split on the digital imaging issue. One office leased a digital imaging system as a convenience to patients and physicians.

“[The office] decided to lease [because] you could buy the system at some stage if you felt it was really good, but on the other side of the coin, if some new technology came out that was significantly superior to what you had, it would be potentially an easier transition,” Wong told Orthopedics Today.

The other office, situated next to an independent X-ray office, chose to stick with plain film X-rays.

One reason Wong cites for using plain film: “Printing out the films still has some benefits in terms of not having to worry about the quality and opening issues.”

His practice still runs into problems with opening images in particular formats from CD-ROMs, which Wong said is due to so many incompatible formats. “It’s really unclear which of the systems is going to end up being the long-term player in the market,” he said.

Another important issue for Wong is presentation. “[Digital imaging] has just not gotten that sophisticated in terms of what’s available either in the office or the operating room,” he said. “Usually … you can put up two views – an AP and a lateral – but if you’re working in situations like we are with spine MRIs … you really need to be able to look at the stack.”

The days of no plain film

Tasto and Wong agree that right now their practices are not at a disadvantage without digital imaging. However, they also predict that plain film will become obsolete in the future.

Tasto compares digital imaging to slides – something that orthopedists never thought they would stop using. “[Now] everybody’s doing PowerPoints and everybody has their pictures in storage,” he said.

Cost, and the industry’s ultimate ability to resolve lingering format issues, will determine when digital imaging becomes universal.