Date: Fri, 5 Jul 2002 08:26:59 -0500

From: Gruenwald, Michael

Subject: Going Filmless

going filmless anybody?

our radiology department is going filmless, everything is going to be on computer screens.

templating and preop planning as we knew it is OVER, quality of images is borderline to unacceptable, it is left to the surgeon to manipulate/ adjust image quality.

no side by side viewing of CT/ Judets...

loading times unacceptable

cost of workstation to be carried by Ortho Department.

anybody having similar scenarios, and how do you fight back??

Johannes M Gruenwald MD FACS
Associate Professor of Orthopaedics
Head, Orthopaedic Trauma Section
UAMS, Little Rock, AR

Reply at: Orthopaedic Trauma Association forum

Date: Fri, 05 Jul 2002 06:55:14 -0700

From: Chip Routt

Don't fight.

Learn to use it, change is good, you may even like it.

Communicate with your radiology colleagues. They need to understand your true needs, and then you can work with them to deliver expert care.


M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
Seattle, WA 98104-2499

Date: Fri, 05 Jul 2002 08:59:06 -0500

From: Andrew H. Schmidt

We've been moving this way at HCMC for several years now. Overall, it is working okay, and in some respects much better. Our workstations have two side-by-side monitors so that we can look at two studies simultaneously. Once you get used to it, scrolling a CT or MRI in "movie" mode is helpful. We have connected one of the workstations in our conference room to an overhead computer projector, so we can now use the electronic images for conferences, etc without have to mess with the file room at all. We can pull up any study in any patient for the last several years with only a 60- 90 second wait. All of the new bone films are put in the system automatically, so it is easy to have the residents show everything that they saw in the ER overnight on morning rounds. With respect to the OR, the radiology techs simply print up hardcopies for us to use. They also deliver hardcopies of the postop or intra-op films, which we can then keep (I often give them to the patient). Finally, we are able to archive every case from our conferences on CD's very easily. It has been great for preparing talks, etc.

Andy Schmidt

Andrew H. Schmidt, M.D.
Faculty, Hennepin County Medical Center
Assoc. Professor, Univ. of Minnesota
Minneapolis, MN

Date: Fri, 05 Jul 2002 10:49:03 -0400

From: Kevin Pugh

Change is difficult at first, but I can echo Andy and Chip's sentiments.

We have 2 23-inch flat screen monitors on our ORs to see films. We have sterile keyboard covers so that we can manipulate images during the case if needed. The archival is great for making talks down the road. We do our conferences in the morning looking at a slide screen and show the films with a projector hooked to the system. Making powerpoints for teaching conferences is a breeze.

Templating is harder, but you can mark up the films using the software on the system. Talk to the software people at your hospital, they may be able to modify things for you. On call, you should get them to allow you to access the images via a VPN network on your home computer, and you can actually go over the film with the resident as you talk to them about the case. No more frustration as they have trouble describing the film to you...and you can pick the correct implant before you head in at 2am.

If the change is being forced on you, I would fight the fact that you must bear the cost. These sytems save the hospitals HUGE money in archival and film room costs. If they are driving the conversion, they should pay the cost.


Date: Fri, 5 Jul 2002 20:17:44 +0100

From: chris wilson

We have been filmless in the clinic, ER and OR for 3 years now. Initially our concerns were like yours but as each individual surgeon has grown more comfortable with the software, the viewing times etc. have gone down. The image quality is very high with our system (a Kodak system I think, but I could check if you want), and it may be that your system is simply set to a poor display resolution, and that the experts can set the windows to a higher quality image.

It means that xrays never get lost,or the packet ends up in someone's car boot when it's needed in the meeting.

Bear in mind that virtually all the digital xray ststems allow hard copies to be printed, and when hard copies are needed for specific purposes, as in your Judet views to go alongside the CT scans, these can be created.

We found that our radiology colleagues were defensive and uncooperative when we started by criticising the system, but when we were more positive and embraced its uses more, they were helpful,and revealed a load of features in the system that we never dreamed of using but which are really valuable e.g. the ability to create individual worklists that a clinician can use to create his or her own "file" for easy retention and storage of interesting xrays whilst you are getting on with your day-to-day clinical practice.

Chris Wilson
Knee and Trauma Surgeon
University Hospital
Cardiff, UK

Date: Mon, 8 Jul 2002 06:56:27 -0400

From: Benedetti Gary E Maj 74 MDOS/SGOSO


Most of the larger military hospitals have gone digital for some time now. It is true that you never loose any films (except when the computer is down, then you have nothing), but I still long for the days of plain radiographs:

The image quality is partially determined by the quality of the monitor. Of course the radiologist all have the high end monitors, but the everyday work stations in the Orthopaedic Department are lacking. Certainly hard to see trabeculae, fine defects on the screen.

Bit of a challenge to compare studies "side-side" without a special set up.

Templating is almost impossible. Is a challenge to get 0ne-One films. There are systems to do on screen templating ($).

Since the image contrast, etc, can be adjusted on the screen, the technicians are losing the ability to look at a patient, and adjust mass/kV to get the best film. It is no fire and forget. This leads to a fair amount of repeat studies.

Have yet to see a decent portable digital image of a chest, hip or pelvis.

We have direct capture, but it still seems like it takes just as long to shoot a study.

Good Luck!

Gary E. Benedetti, LtCol, USAF, MC, FS
Orthopaedic Trauma Surgery

Date: Mon, 08 Jul 2002 09:21:24 -0400

From: James Carr

Radiology sometimes hates the idea they exist to serve us & our patients- sort of like anesthesia. The problem is that in house has to use them even if their service sucks, so they can be as bad as they want. They can print hardcopies if the monitors are not available in the OR. They can print whatever hardcopies you need. Overall, I like filmless as it sure beats tracking the hardcopy around the hospital. I agree that forcing the cost of the monitors on your dept. is unfair. I doubt they spread the cost of new ortho equipment on others.


James B. Carr, MD
Palmetto Health Orthopedics

Date: Mon, 08 Jul 2002 08:20:20 -0500

From: Steven Rabin

Our system is also eventually going filmless with the single overriding reason being that the radiologists can then bill more efficiently. (No lost films or delayed readings of films because the clinical service needed them to treat patients...) The quality of the films is improving but still not good enough when looking for subtle changes in pathologic lesions and looking for signs of healing in osteoporotic bone, but we'll all have to get used to it. Unfortunately I also like to show my patient's their injuries for their own education and understanding (a picture is worth a thousand words) and that is now also difficult to do as we do not have a computer screen in the examining rooms. The only solution we have at the current time is that our radiology department is still willing to print out film versions in addition to the digital images stored in the computer.

Good luck.

Date: Mon, 08 Jul 2002 11:59 PM

From: Bill Burman

>going filmless anybody?

See HWB 2000 Annual Mtg presentation by Ed Harvey of McGill and a review of an early PACS implementation at Vanderbilt.

Bill Burman, MD
HWB Foundation

Date: Tue, 09 Jul 2002 11:02:39 -0400

From: James Carr

Interesting link Bill. Confirms what I said about radiology acting independent without much thought to their customers - the clinicians. I'll wager ortho is one of the few specialities affected so significantly. Most other docs wait for a radiologist to read the film - they don't need to see any film. I once outread one of our internists regarding a lower lobe lung infiltrate - pretty sad. Orthopedist need a bit more info than "a fixation device has been inserted". My advice is to go hybrid - have the radiology dept print whatever film you need - e.g. surgery, clinic, pre-op planning. As long as the film gets entered digitally, they really don't care what happens to the print. Since we utilize CTfor just about every body part, I get less concerned about missing femoral neck fx. McGill sounds like they are on the right track at trying it totally filmless.


Date: Tue, 9 Jul 2002 12:36:30 -0500

From: Wasylenko, Mark

No, we have not decided to go filmless, but who gets the profits from the reading and technical component of the films? If it is radiology or hospital, orthopaedic has NO RESPONSIBILITY for any costs.

Mark J. Wasylenko MD