In the last few years, the radiology equipment install base in the U.S. has undergone a dramatic shift. What was once done with film had been replaced with computed radiology (CR) technology, and now the transformation has gone a step further with approximately 80 percent of providers moving to digital radiography (DR).

The Consolidated Appropriations Act of 2016 provided financial incentives to make the switch, (it introduced reimbursement hurdles for providers who continued with non-DR X-ray technology), but ramping up a new type of technology can be challenging on the front lines. We spoke to Elizabeth Evans, X-ray modality manager at AdventHealth, to find out how she and her team have worked to perfect the process.

HCB News: AdventHealth has made a big shift toward digital radiography in the last few years. Can you talk a little bit about the top-level factors that contributed to that decision?
Elizabeth Evans: For us there were several factors that went into the decision to move our fleet to DR. In terms of functionality, it gives us the highest quality images possible with faster exams. That means productivity and efficiency of workflow are improved. Switching to DR also means we can continue to receive 100% of our Medicare reimbursement.

HCB News: Can you tell us a little bit more about the efficiency advantages compared to CR?
EE: With DR an X-ray is immediately converted into an image, which can be seen on a high-resolution monitor within seconds. This eliminates the steps of digitizing an image, as with CR imaging, which can take from 30-60 seconds. At high-volume hospitals and imaging centers, that is a significant time savings.

The other advantage is not maintaining and cleaning the CR equipment. This was a very time-consuming process for larger sites, with upward of 150 CR cassettes. CR cassettes had to be cleaned regularly, as did the CR digitizer.

HCB News: What about for patients, does DR improve their experience?
EE: DR imaging provides higher quality images using lower doses. Which, in turn, means patients with subtle pathologies have a higher chance of detection where DR imaging is utilized. This is because DR technology provides more advanced image processing.

HCB News: For hospitals implementing their own DR technology, what kind of recommendations can you offer in terms of preparations and staff training?
EE: Making sure there is a complete and comprehensive study tree ensures ease of use for the technicians. Some things sites can standardize include views needed (AP, Lat, or Obl). This way techs won’t have to add views during an exam. Reject reasons and common annotations can also be standardized.
Managing the exposures used is also important and should be set up properly at implementation of the DR system. These can be changed over time but should be set to a technique that makes sense for the body part being imaged.

Making sure the techs understand the differences between CR and DR will also be vital when implementing a DR system. Education should be done with the team prior to a new DR system being installed. This will help establish a basic understanding before the chosen vendor comes in for applications training on the new unit.

HCB News: What kind of feedback, positive and negative, do you hear most often from imaging departments that are introducing DR technology?
EE: There is an abundance of positives and I think we’ve addressed many of them already. Some of the negatives that you hear about across the industry include dose creep, lack of collimation, and improper shielding placement.

Dose creep is when techs use more radiation than necessary to decrease image noise. This is why it’s so important to have a quality monitoring program in place. Collimating the X-ray beam to the area of interest before exposure is very important in digital imaging. DR receptors are more sensitive to low levels of radiation, and the resulting digital image might demonstrate reduced image contrast because of excess scatter radiation striking the receptor. Shielding placed in the FOV can also be a problem. This could cause increased dose, which could cause the area of interest to be overexposed or obscured. At AdventHealth we’ve chosen to eliminate the use of patient shielding during X-ray and CT exams.

HCB News: Are there any tips you can share to ensure DR technology is being used optimally going forward, from the actual implementation?
EE: There will always be opportunities for improvement, even with a DR system. Three things that can be “easily” monitored are: quality, productivity, and dose. I say “easily” because the data is readily available, but it’s not always easy to manage the improvement cycle.

Quality monitoring can include: exposure index management, repeat/reject analysis, and image critique. These factors are important to ensure the radiologist have all information needed to perform their interpretation. Having a digital imaging system can help increase productivity with proper training and support. The time it takes to process an image goes from minutes to seconds. The techs have several indicators letting them know if an image is acceptable by the standards set in their department. There are four components that can affect dose; exposure/technique, AEC, collimation, and shielding.

As leaders we are expected to have a substantial knowledge base and wear multiple hats. Part of our job is to guarantee the following are occurring; a healthy workplace culture, collaboration, training and quality monitoring. It’s extremely important to be diligent in monitoring quality. Using data analysis to identify trends, create education plans and perform follow-up.