Solved: A Consistent and Simple DR/CR Interface

Hospitals trying to send both CR and DR images to PACS, especially for the same patient, have encountered multiple problems in the past. CR and DR images acquired for the same diagnostic study, but through differing devices, might have been presented with a different look and feel because of the technologies with which they were acquired, delaying interpretation. The images might also have had differing exposure, contrast, and resolution, sometimes annoying and distracting technologists and radiologists. More troublesome than the image problems themselves might have been the workflow delays that resulted when PACS administrators were forced to reconcile CR and DR images for the same patient into a single patient case. Technologists could also find themselves using different workstations and software tools, or creating an extra step by sending CR and DR images to a centralized workstation for quality assurance (QA) on those same datasets before they could even be sent to PACS. Workflow delays in the radiology department were a problem that Russell E. McWey, MD, remembers well. At the Virginia Hospital Center (VHC) in Arlington, Va, technologists used to queue at a QA workstation waiting to process images, he says.

“There was a traffic jam. If you had five technologists QA-ing at the same station, it either went down or logjammed.” —Russell E. McWey, MD

Now, McWey says, there are no logjams. Moreover, he adds, the consistency and quality of the hospital’s CR and DR images, once they reach the PACS, are so uniform that it’s doubtful that radiologists even know whether they are looking at CR or DR. McWey, who is medical director of radiology and chief medical information officer for the Virginia Hospital Center, says that the DR/CR solution that the hospital relies on was developed by its PACS vendor, Fujifilm Medical Systems USA, Inc. “We’ve been digital about eight years now,” he says. “My department has been totally digital for three years.” VHC was, McWey says, one of the first hospitals on the East Coast to install Fujifilm’s Synapse PACS. He says that going digital has been “a huge efficiency booster, about ten times better than I thought it would be.” All the prior examinations for a patient, whatever the modality, can be accessed and pulled together in seconds, he adds. Four years ago, VHC moved into a new 330-bed hospital at a cost of $150 million. McWey says that another first with Fuji was scored when the new hospital became one of the first in the East to roll out Fujifilm’s SpeedSuite DR imaging system and its companion CR technology, FCR®. “We have a good relationship with Fuji,” McWey says. “They tell us about their new products and we usually go with them. They’ve been very good, and [for SpeedSuite] they had a top-notch technical team.” It turned out that Fuji’s CR/DR solution was just what VHC had been seeking. Enter the Flash IIP As part of its SpeedSuite DR and FCR technology, Fujifilm has developed advanced image-processing software and a user console (in fact, a technologist and QA workstation) that it calls the Flash IIP (or imaging information processor). The IIP is a clever device that allows DR and CR images for a single patient to be processed in the same patient folder and sent to the PACS as a combined dataset that makes up a single diagnostic examination. In the event that CR and DR images are ordered under different accession numbers, those FCR and FDR images can be combined into the same patient folder at the IIP prior to transmission to PACS. Moreover, both the DR and the CR images are derived in a way that gives them consistent, uniform quality, McWey says. With a few clicks, the technologist or a QA specialist can evaluate and adjust the images and push them onto the PACS. Essentially, what Fuji did, in designing its system, McWey says, was use its image-enhancement processing for CR and apply that to the DR system, even though it uses a different acquisition technology. One of the chief differences between DR and CR normally is that DR images are derived directly and electronically and can go straight to PACS. CR images, on the other hand are derived through the use of a cassette that registers the image on an imaging plate and must be processed to get the images ready for the PACS. Fujifilm’s technology, McWey says, “is CR adapted to a DR platform.” SpeedSuite DR uses a phosphor-based detector to capture the image, but there’s no cassette. The image is immediately sent to the IIP, where the technologist can perform quality control using the same user interface and processing tools, McWey says. Systems include a stand-up wall unit that can be used for chest and other upright examinations and a table where the patient is placed for prone or supine exposures. SpeedSuite comes with two types of detectors; one is a cesium-bromide detector and the other uses storage phosphor technology. Images are scanned using HD Linescan. “Its detector uses a similar technology to CR,” McWey says. “Each detector uses a phosphor-based technology within it. Images are recorded on the detector, but sent immediately to the workstation for review.” The Fujifilm DR also has higher resolution, he notes, adding, “Exposure is equal to or less than direct DR or conventional x-ray, and the detector has such a wide latitude to overexposure or underexposure that can also be corrected electronically.” Combining DR and CR By integrating Fujifilm’s CR and DR technologies into a single workstation, SpeedSuite has made combining DR and CR studies for the same patient simple and also has ensured image consistency across the two modes, McWey says. While a cassette does have to be loaded and processed for any CR studies, the fact that both move through the IIP workstation results in consistent, comparable images, McWey says. Because both the DR and CR use the same IIP interface, the workflow is enhanced, he adds. This turns out to be important not only to the efficiency of the radiology department, but to patient care. McWey estimates that 20% to 30% of all diagnostic radiography studies include combined DR and CR scans. The hospital does an estimated 70,000 radiographic studies per year, he says, so the number combining CR and DR is considerable. Conventionally, DR is used for chest or body studies in which the patient only needs to stand straight or lie flat. For complex positioning or for views involving compromised patients, the more portable CR cassettes are used. CR, McWey says, is especially useful for trauma patients who may too unstable to move. They can be put on a table and scanned using DR for some things, but for other views, CR is needed. “Suppose you’re doing a lumbar spine with a trauma patient. You might do the anteroposterior views with the DR. Then you need a side image, but you can’t roll the patient, so you put the CR plate at the side and shoot across the patient,” McWey explains. Normally, the DR exposures would be done first; then the study would be suspended, the CR plates would be put in place, and the study would be resumed. The DR images would be processed and evaluated at the Flash IIP, with the CR images processed and evaluated at the IIP as part of the same seamless patient examination. Only when the whole patient study was completed and evaluated would it be sent, under a single accession code, to the PACS. “The person reading at the PACS wouldn’t know if it was CR or DR. That person just sees two sets of images, and they all pop up like one study,” McWey says. “The beauty is you get the same image data and the same resolution.” There is one caveat: SpeedSuite and the Flash IIP only work with each other and with the Synapse PACS. “It has to have the Fuji dataset,” McWey says. Connectivity and QA VHC has its diagnostic radiography department configured as three exam rooms, with a SpeedSuite DR and a CR plate reader in each. “Each room has its own control station, with IIP associated. You get the images on the workstation, and then you use the IIP,” McWey says. The IIP can process both DR and CR images and combine them into a study before they are sent to PACS, but it can do more than that. The images can be adjusted to achieve desired presentation states. “On the workstation, there are presets that you can call up to look at bones, lungs, or line placement. The IIP actually changes the processing algorithm,” McWey says. “It doesn’t matter if it’s CR or DR; it still has that capability.” The IIP is used to process the images and to complete whatever QA is needed. The technologist uses the IIP to get the images ready for the PACS. Then they’re sent, McWey says. He explains, “The IIPs are combination units with multiple functions. When you acquire a CR or DR image, the IIP is in study-reception mode, and it displays the image from the DR or CR so you can check positioning and see if that’s good enough. To do QA, you hit a button that allows you to crop, magnify, change density, and change contrast. Every IIP has that capability.” Another huge plus is connectivity. The IIPs can be linked, as they are at VHC. A technologist at any workstation can receive and process images coming from any of the imaging rooms. This results in added efficiency. “During the week, we have a daytime supervisor who does QA for all the images, but our weekend technologists have been trained to do QA for their own studies at their own workstations,” McWey says. “It’s a distributive-elective, function so you can send to any IIP. That makes it multiredundant, too.” The Cost Factor McWey says that the Fujifilm DR/CR technology and the Flash IIPs have increased efficiency in the department, so that more work gets done without adding staff. “Our diagnostic load has been pretty flat, so I can’t give a good correlation to what it was. It’s higher now but nothing dramatic. Our day-to-day productivity is easier, and the work gets done more rapidly. We definitely have the capability of higher throughput. I just don’t have those numbers,” he says. He also says that there’s a huge cost advantage to using the Fujifilm SpeedSuite and Flash IIP system. He estimates the deployment cost as about two thirds of the cost of a conventional DR exam room with a CR addition. “The conventional DR is really expensive, and it’s $100,000 to replace that detector plate,” McWey says. He adds that Fujifilm's plates are durable and cost much less. VHC didn’t rush into its decision to adopt Fuji CR/DR, despite its long relationship with the company. “We looked at many DR systems,” McWey says, “but some of them required a cooling system, and that was noisy. We don’t have any of that with Fuji.” There were, of course, a few minor glitches when the SpeedSuites and Flash IIPs were installed. “There were a few issues with applications. If a technologist chose the wrong examination, there could be a recovery time for the detector to refresh, but Fuji changed the software, so it’s no longer possible to do that. The other issues were nuisances. They had to modify some things like protective covers and contact switches that would deactivate. They put in stronger ones. It hasn’t been an issue since then,” McWey says. With SpeedSuite and Flash IIP, VHC got what it wanted, McWey says: “A system more consistent and easier to use, with seamless integration of CR and DR.”