by Mike Weiss

Since then, they've gone from developing faint pictures of broken bones to conducting specialized scans that can spot anything from potentially threatening tumors to tiny clots of blood.

But along the way, one thing has remained constant: the sheets of film that doctors hang on wall-mounted light panels, studying the images and looking for anything out of the ordinary.

"We've been using film for more than 100 years," says radiology technologist Jackie Bridger, a clinical operations manager for Emory Healthcare. "It's probably the only thing in medicine that hasn't changed."

Until now, that is. By the beginning of 2003, Emory Healthcare - Emory University Hospital (EUH), Emory Crawford Long Hospital (ECLH), Wesley Woods Hospital, and The Emory Clinic - will have eliminated those floppy sheets in favor of a new system that replaces the film with digital images on computer screens. ECLH opened its diagnostic treatment center last summer with the new equipment already in place. The rest of the system is expected to join in the new year.

"Obviously, this is something you can't do with film," says Bridger, now the clinical operations manager of the new system.

Called PACS - or Picture Archiving and Communications System - the system isn't exactly new to hospitals in the United States, or even on Clifton Road. About 10% of the nation's hospitals have converted to PACS, including Children's Healthcare of Atlanta at Egleston across the street from Emory. But the sheer magnitude of the installation in Emory's far-flung facilities set it apart from previous efforts, as did the $15 million budget, tight for a system of this size.

Even with belt-tightening throughout Emory, now seemed like the best time to install PACS everywhere in the health system, says Ronnie Jowers, Emory Healthcare chief financial officer. PACS is the kind of cutting-edge technology the Winship Cancer Institute needs to help secure a National Cancer Institute designation, marking it as one of the country's elite. And with the opportunity to design a radiology department from scratch at the recently redeveloped Emory Crawford Long, it made sense to take advantage of the newest, most efficient technology available, Jowers says.

Emory signed on to the effort in 2000, with full funding for installation and the first eight years of operation approved a year later. "The Emory Crawford Long redevelopment definitely forced the issue," he says. "Money for health care is pretty tight. But in the long run, digitizing images that we can send and duplicate whenever we want seemed the way to go."

Aside from any new X-ray and other imaging devices planned for the new Emory Crawford Long anyway, Emory did not have to purchase new equipment, Jowers says. Many of the machines on hand take initial digital images, which can be transferred to film, and those that do not are being retrofitted with new technology. But that expense, plus the cost of installing new cables and wiring thoughout the system's buildings, took up about $10.5 million of the project's total cost.

"It's not just a matter of adding equipment," says Emory radiologist Walt Carpenter, the chief of informatics for radiology at EUH and a member of the committee of physicians overseeing the implementation. "We had to redesign the whole X-ray department and how we do things."

Inside the radiology reading rooms, images can be called up instantly on large, high resolution, high-brightness monitors, using software that aids in interpreting radiologic exams. Or they may be sent to any of the clinical workstations throughout the Emory health system, which allow a physician in one area of the hospital to view images taken in another wing without wasting his time walking back and forth or waiting for the film to be delivered.

With images available to anyone with a password and a home computer with adequate memory, residents working in the emergency department can consult with the on-call radiologist at midnight without making her change out of her pajamas, let alone drive all the way down to the hospital.

Eventually, Carpenter says, the technology could enable Emory to contract with radiologists across the world, who would be able to look at images during normal working hours there.

Most important, though, PACS eliminates the importance of a single sheet of film. It's no secret in the medical community that X-ray film is notorious for disappearing. One doctor takes it to the office for study and leaves it on the desk, or another borrows it for a teaching session with med students, or maybe it's sent off for a consultation and is never returned.

"If it's in someone else's locked office, I can't see it," says Carpenter, whose own office has stacks of film in manila envelopes stacked against the walls. "If I lose it, it's gone forever."

Or maybe it isn't misplaced, but the only tech who knows where it is just went home for the weekend. "In all, 2% to 3% of radiology exams have to be repeated because the film is somehow unavailable," says William Casarella, chair of the Department of Radiology.

That means that expensive procedures are not billed, which translates to as much as $2 million per year. Not only might a patient have to submit to another expensive test to replicate the images, but also the wait may force a delay in her treatment. With PACS, the image is always available.

Last year, for instance, a tech X-raying a patient in the emergency department may have had to walk the unprocessed film to radiology to prepare it, then track down a radiologist for an examination, finally returning the film back to the treating physician in emergency. Now, she doesn't need to leave the equipment, for the images are ready in moments to be studied by a radiologist anywhere else on the campus.

The system also allows patient information to be entered into the computer in advance, saving the technologist the task during the exam. A workstation can be programmed to set up a list of the day's patients before the first appointment in the morning, allowing a tech to simply click on the proper patient's name rather than type in names, addresses, and other data at the time.

That's crucial, because unlike a misfiled sheet of film -- which might be unearthed by hand-searching surrounding files -- a data entry error like a misspelled name or an omitted middle initial can lose an image forever, unrecoverable without somehow duplicating the original typo. So far, those problems have been few and far between, Carpenter says.

While PACS saves time overall, now it's usually up to the doctor herself to call up the images on the computer, not a slow process, but one that can seem interminable to those used to having everything ready for them, Carpenter says.

"The office efficiency goes way up," he says. "But the individual efficiency of the doctor can go down without proper use of the workstation. It's critical that everyone goes through appropriate training."

PACS facts

Currently 4 years' accumulation of film
is kept onsite.

Still, not all physicians are happy with going digital. Film has advantages that a computer image does not, some say.

Surgeons, for instance, who want to refer to MRIs while operating, say the bright lights in the OR make it difficult to look at a monitor. Some radiologists like to look at several images at a time, spread out on a wall of viewboxes, and not have to toggle between them on the screen. And while Carpenter says the resolution of the digital images is excellent and up to the standard of care patients should expect, there are some things - like subtle fractures and tiny kidney stones - that may be easier to pick up looking at film. For those, the PACS team has been accommodating. Surgeons still bring film into the operating room, in part because not enough images are used there to justify the expense of installing the high-resolution monitors in the room, says Casarella. And doctors may still request film, though he hopes those requests will decline as people get more comfortable with the new system. Casarella says film probably won't be phased out entirely for a few years.

"How quickly we start saving money depends on how quickly the doctors get used to it," Jowers says. "The worst thing that could happen would be to have both PACS and film all the time."

Some physicians simply don't want to make the change. A few doctors are computer-phobic and simply can't get the hang of the software. Others just like the feel of a sheet of film in their hand.

"Personally, I have an aversion to film now and prefer soft-copy review. I believe that once everyone gets used to it, they'll never go back," Carpenter says. "But film is what they're comfortable with. It is what they know."

Still, while there may be some grumbling about the changes and this bug or that feature, there hasn't been a lot of disagreement about whether PACS would come to Emory eventually.

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"I don't think PACS is going to generate any great savings over time," Jowers says. "But it should pay for itself."

Doctors should be looking at the other advantages, Carpenter says. "Management paid for it with the savings they expect. But the real reason for doing it is improving patient care."

Mike Weiss is a third-year Emory Law School student and executive articles editor for the Emory Law Journal.