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Computers in Radiology

Bruce I. Reiner 1–3

Eliot L. Siegel 1,2
Technologists’ Productivity When
Using PACS: Comparison of Film-
Based Versus Filmless Radiography
OBJECTIVE. The objective of this study was to assess the impact of filmless operation
and computed radiography on technologists’ examination times compared with conventional
film-based operation and film-screen radiography.
CONCLUSION. Compared with conventional film-screen operation, filmless operation
using computed radiography was associated with a significant decrease in technologist exam-
ination times in the performance of general radiographic examinations. This decrease in tech-
nologist examination times in a filmless environment offers the potential for increased
productivity with resulting personnel savings and improved operational efficiency.

D iagnostic imaging departments

have a dual mission that re-
quires them to maintain the
highest quality and consistency of patient
tional study conducted by the American
Healthcare Radiology Administrators [1],
only 42% of hospital-based radiology ad-
ministrators reported adequate technologist
care while maximizing efficiency and pro- staffing, with an average of 2.8 full-time
ductivity. With the increasing financial equivalent technologist positions unfilled for
pressures placed on imaging providers, general radiography alone.
these goals often become mutually exclu- Although work flow optimization has
sive. Decreased reimbursement rates, in- been well described in the industrial engi-
creased penetration of managed care, and neering literature [2], little to date has been
heightened competition among diagnostic published in the radiology literature. Survey
imaging providers (both in and outside of data published by the American Healthcare
the hospital) have resulted in greater pres- Radiology Administrators [1, 3] describe na-
sure on radiology administrators to de- tional norms for technologist productivity in
crease personnel and operational expenses terms of the number of examinations per-
without compromising the quality and formed by a full-time equivalent technolo-
Received November 21, 2001; accepted after revision quantity of imaging services. gist, but these surveys do not evaluate the
January 9, 2002. To facilitate these changes, administrators individual variables contributing to produc-
Department of Radiology, Veterans Affairs Maryland have placed greater emphasis on increasing tivity measures. Although three groups of
Healthcare System, 10 N. Greene St., Baltimore, MD 21201.
productivity in the imaging department. Be- investigators [4–6] have attempted to esti-
Department of Radiology, University of Maryland School cause most hospitals do not employ radiolo- mate the average time for various technolo-
of Medicine, 22 S. Greene St., Baltimore, MD 21201.
gists, the primary focus of productivity gist functions in the performance of general
Present address: 6 Greenleaf Ln., Seaford, DE 19973. enhancements has been on technologists. radiographic examinations, these reported
Address correspondence to B. I. Reiner.
This strategy takes on even greater impor- procedure times vary by as much as 300%
AJR 2002;179:33–37
tance in the current job marketplace given [7] because of a number of difficult-to-con-
0361–803X/02/1791–33 the extreme shortage of qualified imaging trol variables including uneven and unpre-
© American Roentgen Ray Society technologists. In a recently published na- dictable patient flow; technologist fatigue;

AJR:179, July 2002 33

Reiner and Siegel

and additional requirements for administra- period. Examination time was defined as the time filmless operation at the Baltimore center, com-
tive, supervisory, and educational activities. from patient arrival in the examination room to the puted radiography was performed using a plate
With the advent of computer technologies time completed images were ready for radiologist reader (AC-3; Fuji Medical Systems, Stamford,
in the imaging department, some of these interpretation; this period was timed by indepen- CT) that is interfaced with the hospital and radiol-
dent observers using a stopwatch (Fig. 1). Any de- ogy information systems (Veterans Health Infor-
operational inefficiencies can be addressed
lays or interruptions during the course of each mation Systems and Technology Architecture) and
through the combined use of computed radi- study were recorded and included in the data anal- a commercial PACS (General Electric Medical
ography, hospital and radiology information ysis. Data were recorded during routine weekday Systems, Milwaukee, WI).
systems, and picture archiving and commu- hours of operation, and technologists were aware The prospective time measurements obtained at
nication systems (PACS). This study was that a timing study was being performed. the study institutions were correlated with the na-
undertaken to objectively quantify the effect The two commonly performed types of radio- tional standards for workload in a film-based de-
these technologies have on technologist ex- graphic examinations chosen for evaluation were partment [9]. The two film-based institutions were
amination times. The study focused on the chest (two views) and orthopedic examinations of chosen because of their similarities in technologist
performance of general radiographic exami- the spine (three to five views). Portable examina- staffing, patient demographics, and location. The
nations, which constitute 60–70% of a hos- tions were excluded from the study because of the Philadelphia and Baltimore centers are also com-
large variability in work flow steps for these stud- parable in examination volume, modality mix, and
pital’s imaging department volume [8]. By
ies among and within the three facilities. Conven- presence of a strong academic affiliation.
analyzing work flow using time–motion tional film-screen radiography was performed at Statistical analysis was performed using both
studies, we attempt to better understand the two of the three study institutions (Fort Howard one- and two-way analyses of variance to evaluate
complex relationship between these digital and Philadelphia Veterans Affairs Medical Cen- differences in technologist examination time
systems and technologist productivity. This ters), and filmless operation using computed radi- among the three study institutions, between film-
information can assist imaging providers ography was used at a single study institution based and filmless operations, and between the
with objective measures for cost–benefit (Baltimore Veterans Affairs Medical Center). two types of radiographic examinations evaluated.
analysis when contemplating a transition to For the film-based operation at the Fort Howard
filmless imaging. center, film-screen cassettes (Curix; Agfa, Ridge-
field Park, NJ) were manually developed using a
conventional processor (RP Xomat [model M6B];
Eastman Kodak, Rochester, NY). For the film- Prospective time measurements revealed
Materials and Methods based operation at the Philadelphia center, film- significant time savings for filmless operation
Prospective time–motion studies were per- screen cassettes were developed using a daylight (Table 1) for both categories of general radio-
formed at three medical centers during a 1-week processor (ML 700; Eastman Kodak). For the graphic examinations evaluated ( p < 0.001).

Common Steps for Film-Screen and

Filmless Computed Radiography
1. Review requisition (paper or electronic).
2. Escort patient to radiography room.
3. Position patient and acquire images.

Film-Screen Radiography (Fort Howard) Film-Screen Radiography (Philadelphia) Filmless Computed Radiography
1. Place exposed film in pass box. 1. Place exposed film cassettes into
2. Develop film images, remove film from cassettes, daylight processor. 1. Place computed radiographic
place film images into conventional processor, 2. Complete paperwork (historical and images into plate reader.
refill empty cassettes with new film, replenish film demographic information). 2. Enter unique case information
bin if empty. 3. Remove film images from daylight into computer and open
3. Complete paperwork (historical and demographic processor. electronic folder for patient examination.
information). 4. Refill empty cassettes with new film. 3. Review computed radiographic
4. Remove film images from conventional processor. 5. Review processed film images for images on PACS workstation
5. Review images for quality control. quality control. and edit as needed.
6. Annotate images and obtain repeated images as needed. 6. Annotate images and obtain repeated images 4. Verify examination electronically and
7. Collate film images and paperwork. as needed. close folder.
8. Pull patient master film jacket from file room. 7. Collate film images and associated
9. Pull pertinent comparison film images and reports paperwork.
from film jacket. 8. Take completed study to file room
10. Submit unreviewed films for radiologist interpretation. for radiologist interpretation.

Fig. 1.—Schematic drawing shows differences in work flow among imaging departments using conventional film-screen radiography with a conventional processor, conven-
tional film-screen radiography with a daylight processor, and filmless computed radiography. Number of steps is reduced to four with filmless computed radiography because
steps related to film processing and handling can be eliminated.

34 AJR:179, July 2002

Technologists’ Productivity When Using PACS

For posteroanterior and lateral chest radio- the national range for a three-view cervical fer of additional responsibilities to other im-
graphic examinations, significant differences spine study or a five-view cervical or lumbar aging department staff members. The net
were found when comparing the filmless spine examination. effect on improved operational efficiency is a
study site with the two film-based sites ( p < substantial reduction in examination times
0.001). A mean time savings of 3.4 min (Table 1). Thus, using computed radiography
(31%) was observed when comparing exami- Discussion and operating in a filmless mode save a sig-
nation times at the film-based Fort Howard Although time–motion analysis in tech- nificant amount of technologist time.
center with those at the filmless center. A nologist performance of radiographic exami- In a film-based department, technologist
greater mean time savings of 6.6 min (47%) nations is a valuable exercise, it represents work flow typically consists of responsibili-
was observed when comparing the film-based just a single phase in the complete radiogra- ties that overlap with those of clerical and
Philadelphia center with the filmless center. phy work flow process, which begins with film library staff. Technologists are typically
The mean examination time required for a the examination order and ends with the de- asked to perform functions that involve film
posteroanterior and lateral chest study at the livery of the final radiography report. A pre- collation and distribution. These additional
Fort Howard center was similar to the na- vious analysis of this work flow process steps were not fully accounted for in our
tional norm [9], which is approximately 10 during film-based operation at the Baltimore study design, which recorded the interval
min, whereas the mean examination time at center enumerated 59 individual steps [10], from the time the technologist greets the pa-
the Philadelphia facility was substantially underscoring the relative inefficiency of most tient to the time the images became available
longer than the national average. The exami- film-based imaging departments and the ne- for review in the film library.
nation time at the filmless medical center was cessity for work-flow optimization. In the case of filmless operation with
substantially lower than the national average. We found a substantial difference in the computed radiography, each examination
The difference in the mean examination number of work-flow steps for technologists ended and the timer stopped timing the ex-
time for imaging the spine was also signifi- when comparing examination times for film- amination once the images became available
cant when comparing film with filmless op- based and filmless operations (Fig. 1). After on the PACS for review by radiologists and
erations ( p < 0.001). A mean time savings of the technologist acquires the radiographic clinicians. However, for the film-based oper-
5.1 min (37%) was observed when compar- images, an additional seven to 14 steps were ations, examinations ended after the tech-
ing film-based operation at the Fort Howard required for the film-based facilities in our nologist had collated the images and
center with filmless operation at the Balti- study, depending on the individual depart- paperwork with the hard-copy film jacket
more center. This mean time-saving with ment’s technology, work flow, and ancillary and had returned the entire file to the film li-
filmless operation was significantly greater personnel. Using a daylight processor in lieu brary. Although a technologist’s responsibil-
when comparing the Baltimore and Philadel- of a conventional processor or assigning ities in a film-based environment often
phia centers, with a 12.0 min (58%) savings. these tasks to a darkroom aide, a technolo- involve these additional steps, we did not
The examination times from the film- gist can eliminate the four steps related to time these steps for our study. This omission
based institutions are comparable to the na- image processing. At the same time, an ad- may have resulted in the underestimation of
tional norms, which have been reported as ditional three steps can be avoided by trans- the time-savings associated with filmless op-
ranging from 11 to 15 min for a three-view ferring all the responsibilities for image and eration. Moreover, we did not record the ad-
cervical spine study, 15–22 min for a five- report collation, transport, and hanging to ditional time required for film-room staff to
view cervical spine examination, 8–15 min file room staff. Although this transfer of re- make the images available for interpretation
for a three-view lumbar spine study, and 20– sponsibilities can result in improved tech- by radiologists or review by clinicians be-
30 min for a five-view lumbar spine exami- nologist productivity, it creates additional cause the focus of our study was on technol-
nation. The lower ends of these ranges refer work for and diminishes the productivity of ogist productivity.
to ambulatory patients, whereas the upper other staff members. Regardless of whom From the results in Table 1, several obser-
ends refer to nonambulatory patients. The the work is assigned to, it still must be com- vations that are attributable to the unique
combined examination time for all spine pleted in a film-based department and re- characteristics of the study sites can be
studies at the filmless Baltimore center was sults in operational inefficiencies. made. The film-based Fort Howard center is
at the bottom of the range for a national Filmless operation results in a reduction of an affiliate of the Maryland Veterans Affairs
three-view lumbar spine study and below these 14 steps to four steps without the trans- Healthcare System, largely serving a less

TABLE 1 Technologist Examination Times When Using Film-Screen Radiography Versus Filmless Computed Radiography

Examinations Using Film-Screen Radiography Examinations Using Filmless

Type of No. of Computed Radiography at the
Fort Howard Center Philadelphia Center Both Centers Baltimore Center
Examination Views
Mean Time (min) No. Mean Time (min) No. Mean Time (min) No. Mean Time (min) No.
Chest 2 10.8 146 14.0 173 12.5 319 7.4 185
Spine 3–5 13.9 53 20.8 160 19.1 213 8.8 160

AJR:179, July 2002 35

Reiner and Siegel

acute, ambulatory outpatient population. Be- examination ordering, scheduling, and track- 50,000 additional radiology technologists
cause patient populations differ at the two ing; image management; reporting; billing; will be needed by 2006 (Devereaux K, per-
film-based institutions, technologist exami- and statistical analyses. sonal communication). As the shortage of
nation times also differ: examination times A number of specialized integration en- technologists increases, work demands and
at the Fort Howard facility are shorter than hancements, such as a Digital Imaging and stress will continue to increase, potentially
those at the Philadelphia facility, which COmmunications in Medicine (DICOM) diminishing technologist productivity.
serves a mixed inpatient and outpatient pop- modality work list, are available to further A number of potential improvements can
ulation. Many of these inpatients are less augment technologist productivity. The use address technologists’ increasing stress levels
ambulatory and are consequently more diffi- of this feature can markedly reduce errors in and reduced productivity. As previously dis-
cult to position for the technologist perform- patient and study identification and can re- cussed, work-flow optimization is a critical
ing the study. The patient profiles of the sult in automatic, more rapid entry of pa- objective and can be further enhanced by
Philadelphia and Baltimore centers are simi- tient information into the computed software developments, which continue to re-
lar to one another; therefore, times from radiography system. For example, another duce the number of manual steps required in
these two centers present a more accurate study evaluating CT transmission failure the processes of data entry, image acquisition,
comparison between film-based and filmless rates in a digital imaging department de- review, and processing. Greater distribution
imaging operations. scribed an initial failure rate of 8% [11]. Of of computed radiography plate readers
The musculoskeletal imaging studies these transmission failures, 69% were the throughout the medical enterprise can further
were heterogeneous, both in terms of the pa- direct result of human error, specifically reduce technologist travel time to and from
tient populations and specific types of exam- data entry errors. These errors caused sig- the sites of image acquisition.
inations. For ambulatory patients, who nificant time delays for the technologist. Areas of high volume, such as emer-
predominate at the Fort Howard facility, the With the advent of the modality work list, gency departments, intensive care units,
examination times tended to be shorter be- transmission failure rates decreased by and outpatient clinics, should have dedi-
cause of the relative ease in positioning the 56%, resulting in enhanced operational effi- cated plate reviewers to facilitate faster im-
patient. In addition, these examinations were ciency and technologist productivity [11]. age processing. An industry response to
typically requested on a nonemergent basis Another software enhancement, the per- this need has been the development of com-
for chronic conditions, such as lower back formed-procedure step, can be used to further puted radiography systems with in-room
pain. On the other hand, a larger percentage increase operational efficiency by notifying plate reviewers. At the same time, newer
of the orthopedic examinations at the aca- the hospital information system automatically digital technologies are available that elim-
demic facilities (Baltimore and Philadelphia of examination status information. The auto- inate the need for cassettes, further reduc-
centers) were of nonambulatory patients and mation of these processes, which were previ- ing the number of steps required for
were urgent in nature. ously performed manually by technologists, technologists and enhancing work flow.
Both of these factors tend to be associated improves work flow, reduces transfer error These newer technologies include direct
with greater technical difficulty for the technol- rates, and minimizes technologist fatigue. (flat-panel) radiography and cassetteless
ogist, resulting in the expected increased exam- Fatigue and stress seem to play a surpris- computed radiography. Recently published
ination times. These differences in patient ingly important role in technologist produc- studies [15–17] have reported improvement
population and ambulatory status are addressed tivity, but these issues have been largely in work flow with the use of these in-room
in the national benchmarks, which illustrate the ignored in the radiology literature. Two other digital systems.
major differences in examination time between studies found in the film-based radiology lit- The transition from use of film-based to
these different patient populations. erature suggested that up to 20% of a technol- filmless technologies in an imaging department
One of the limitations of our study was the ogist’s examination time is attributable to offers tremendous potential for work-flow re-
relatively small sample size for each individ- stress and fatigue [7, 12]. After transition design and, consequently, improvements in op-
ual category of examination studied, which from the film-based to filmless operation, us- erational efficiency for technologists in the
precluded a detailed analysis of ambulatory ing computed radiography and PACS, tech- performance of general radiographic examina-
and nonambulatory patients or of a specific nologists reported reductions in perceived tions. Although filmless operation at the Balti-
anatomic region (e.g., cervical vs lumbar levels of stress and fatigue [13, 14]. more center was associated with substantially
spine). In spite of the sample size, however, The concept of job-related stress takes on lower examination times than the two film-
significant differences for the examination even greater importance in the current imag- based facilities or with national benchmarks,
categories were observed for all three study ing environment because of the increasing we believe that additional improvements are
sites evaluated. shortage of qualified radiology technologists. possible with the use of in-room radiography
In addition to the use of computed radiog- According to data from the American Soci- systems and increased system integration. As
raphy and a filmless mode of operation, the ety of Radiologic Technologists (McElveny imaging departments become increasingly inte-
use of a radiology and hospital information C, personal communication), the number of grated with the rest of the health care enterprise
system and the degree of integration with first-time technologists taking certification using tools such as the DICOM modality work
computed radiography and the reliability of examinations in radiography decreased by list and the performed-procedure step, technol-
these systems are critically important to 49% between 1994 and 2000, with a de- ogists in both film-based and filmless depart-
work-flow optimization. The hospital and ra- crease in the number of technologist training ments will likely continue to become more
diology information systems can be used to programs of 19% over the same time period. productive without concomitant increases in fa-
improve work flow in patient registration; The Bureau of Labor Statistics estimates tigue and stress.

36 AJR:179, July 2002

Technologists’ Productivity When Using PACS

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AJR:179, July 2002 37