Serving your practice through digital imaging

Life, it seems, is being reduced to a digital format. Documents, music, and photographs have all been reborn as computer files, sweeping away much of our physical clutter, and the public can’t get enough. The ubiquity of personal digital assistants, MPEG music players, and digital cameras prove that convenience and accessibility is the catchphrase of the times.

This digital movement is also catching on in the medical field. Many developments are facilitating efficiency in practice operation. Patient files, billing, and even physician notes all have software programs that eliminate the need for physical filing systems and excessive paper.

Even x-ray files can be created digitally, eliminating the hassle of film storage and processing. It also offers multiple possibilities for efficiency and image clarity. Digital imaging is not a brand-new technology, but it is mostly used in hospitals or large radiology centers. However, a digital imaging system is becoming more accessible.

For more information about how to move into a digital x-ray format for your chiropractic practice, Chiropractic Products invited Fred Fischer of All-Pro Imaging Inc; Penny Maier of FUJIFILM Medical Systems USA; and Terry Yochum, DC, DACBR, a chiropractic radiologist specializing in musculoskeletal radiology; to answer some questions on the advantages of embracing modern technology.

Fischer is senior executive at All-Pro Imaging Inc, a manufacturer of x-ray equipment for the medical profession. All-Pro, located in Hicksville, NY, is an affiliate company of Air Techniques Inc, a dental equipment manufacturer.

Maier is national marketing manager, digital x-ray, for FUJIFILM Medical Systems USA Inc, based in Stamford, Conn. She is responsible for developing and implementing promotional strategies for FUFIFILM’s computed radiography (CR) and digital radiography (DR) product lines, and she oversees new digital x-ray product launches.

Yochum is a professor of radiology at the Southern California University of Health Sciences in Whittier, Calif, and an instructor in skeletal radiology for the University of Colorado, School of Medicine in Denver.

How will a chiropractor who switches from a traditional (film) x-ray format to digital save in the long run (including money, time, and space)?

Fischer: Digital imaging, both DR and CR, eliminates the need for x-ray film, chemicals, used chemical disposal, film storage and duplication, film processor and processor maintenance and repair, and even the darkroom. If you take as few as 8 films per day, the annual savings could be as much as $9,000. In addition, digital images are available much faster than with a processor.

Maier: Managing film processing and storage costs can be a sizable expense to many practices. A study by the Mayo Clinic found the costs for film management to be more than $15 per patient case per year. Eliminating processing chemicals and the environmental considerations of film’s hazardous disposals are a big advantage of going digital. Many users start with printing digital x-ray images to a dry laser imager, which eliminates these costs. When a full transition is made to PACS [picture archiving and communications system], the most significant cost savings are realized; film-archiving costs can then be eliminated and replaced with less-expensive digital archives. Additionally, the physical space taken up by the processor and darkroom can often be converted to more functional space to house new digital x-ray equipment, add counter space, or accommodate other site-specific needs. Many offices find that work flow can be re-engineered with the purchase of digital equipment, converting a dated work-flow process into one that can take advantage of quick image access, available with digital x-ray. Finally, one of the most documented advantages of going digital is the decrease in lost and repeated films. Digital x-ray features a wider dynamic range than film, making it more forgiving for exposure errors and often eliminating the need for retakes. And because a digital file of the image can be archived electronically and accessed to reprint a film as necessary, lost films have been reduced to a fractional percentage of total volume in many environments.

Yochum: The chiropractor will save by having no expense in film and developing chemistry, eliminating the need for a darkroom, and no longer requiring staff time to process films.

How much additional staff training is required?

Fischer: X-ray exposures continue to be made in the traditional way, although there may be some exposure adjustments. DR sends the image directly to a computer; with CR, the reusable plate is removed from the cassette and placed in the scanner, much like using a “dry processor.” The only additional training required is the use of the software to enhance, store, and recover the x-ray images.

Maier: Owning the best digital x-ray equipment does not translate to optimal image quality or improved work-flow efficiency if the staff does not know how to use it. With our company, an experienced professional service team supports every install with at least two visits. The first provides a system overview for the staff to get started. A return visit answers questions and trains staff on more advanced features once they have had a chance to use the equipment. A “super-user” is trained to be an on-site expert for staff, and a hotline is available for users who run into questions along the way and need a quick response.

We’ve found that with a combination of training and the simplicity of our user interface, staff can use new digital x-ray equipment on their own within a few hours. They can feel proficient within a week.

Yochum: No additional staff training is necessary.

What are the benefits to the patient when a chiropractor replaces his film format with digital?

Fischer: Using DR, the patient may have less exposure to radiation. Since the images are available faster than with film, there is less waiting time. Also, since digital systems are more tolerant than film to over- or under-exposure, there will be less need for retakes.

Maier: Digital x-ray makes images available more quickly. This allows staff to determine whether the positioning was appropriate and whether another view needs to be taken before the patient leaves the examination room. This minimizes patient waiting time and the inconvenience of callbacks. Also, lost films can be virtually eliminated, and a patient’s hassles associated with retakes or acquiring a film for a referral can be greatly reduced. Last, depending on the film speed, it may be possible to reduce patient radiation exposure for some exams.

Yochum: The major benefits to the patient are a reduction in the radiation dosage and no repeat x-rays.

How does the quality of the final image compare to that of conventional techniques?

Fischer: Film is a static image. It can be magnified, but otherwise what you see is what you get. Digital images can be enhanced to bring out all of the diagnostic detail. In addition, some software actually allows the doctor to make measurements directly on the computer. This is more accurate and easier than using a ruler and protractor directly on the film.

Maier: The inherent flexibility of digital files present an advantage over film by allowing magnification of a region of interest and giving users the ability to present the image with different processing for optimal display. The wider dynamic range of digital x-ray makes it more forgiving to over- and under-exposure, often making what would be an “unusable” film image salvageable with digital acquisition. Another big advantage to digital x-ray is the availability of advanced image-processing tools to enhance areas of an image or apply computer-assisted diagnostic tools for a second opinion.

Yochum: In many instances the final images are of better quality, since the final density can be controlled by the computer.

What new technologies are becoming available that will be useful for the practicing chiropractor?

Fischer: Until recently, digital imaging systems were so costly, they were out of reach of the average chiropractic office. Today, a number of companies offer simplified versions of digital systems within the reach of the private practice. These new systems provide all of the advantages of digital at a more reasonable price.

Maier: Advanced capabilities available include dual-energy subtraction, which presents three displays of a single PA [posterior-anterior] chest exam—bone only, soft-tissue only, and standard chest exam—with a single exposure to the patient, improving diagnostic accuracy. Temporal subtraction is a new processing software that compares historical chest exams and applies processing to improve visibility of changes between the images. Computer-aided detection is an emerging technology that can act as a second opinion or offer diagnostic certainty for practitioners and patients alike.

Yochum: Neurodiagnostic testing to include nerve conduction velocity (NCV) and needle electromyography (EMG) may prove beneficial for diagnostic evaluation of radiculopathy. These tests are very helpful when x-rays and magnetic resonance imaging (MRI) scans are negative.

Julie Z. Lee is a contributing writer for Chiropractic Products.