Expansion of computed radiographybrings key benefits in Australia

Queensland Health provides public health services across a highly decentralized population base in the state of Queensland. This includes the provision of medical imaging services to 130 facilities. Successive projects to introduce digital image acquisition at these sites began in 2006. The latest of these, the j.net project, was completed in July 2008 and involved installation of computed radiography at 86 sites.

The project's completion made Queensland Health (QH) the first state health service in Australia to provide digital acquisition of general radiographic examinations at all of its medical imaging facilities.

A significant proportion of sites that have medical imaging services provided by QH offer only general radiography (87 sites). Licensed x-ray operators carry out all diagnostic image acquisition work at 77 of these facilities.

Licensed operators are employed at geographically remote locations that lack radiographers. They are licensed to perform a limited range of x-ray examinations and have access to a radiographer within the same district on a supervisory basis. Medical imaging is not their primary role in the health service facility. Many licensed operators are nurses, though the role may also be taken on by a member of the operational or medical staff.

Imaging facilities at remote rural sites typically consist of a single room with fixed or mobile x-ray equipment. When j.net commenced in July 2007, 73 of these sites were using wet film processors.

FIRST STEPS

The aim of the j.net project was to establish a minimum level of digital image capture and processing equipment at all sites. An accurate register of existing equipment was established as a first step. This involved collating survey data from previous projects and following up by telephone to confirm the information.

Existing QH contracts held by Fujifilm Australia and Carestream Health allowed the procurement of the required computed radiography equipment:

• single CR reader;
• “dry” film printer;
• workstation with CD/DVD burning capability.

The same make and model of equipment was installed within each district to assist with training and support.

In addition to the digital acquisition and processing equipment, the following accessory items were provided: antiscatter grids, foam positioning aids, x-ray-compatible patient trolleys, textbooks, and lead aprons.

A site survey tool was developed to identify preinstallation requirements, such as physical space, site access, equipment storage capacity, availability of power and air-conditioning, and availability of data network points on the local area network (LAN). Training requirements were determined by assessing the number of operators and days available for training.

Assistance was given to staff at rural and remote facilities in completing the survey. QH staff who already visited these areas, including engineers and radiographers, provided a basic understanding of the technology and workflow requirements for the transition to digital image acquisition.

Site preparation work began once the surveys had been completed. This proved to be challenging for sites where access to local maintenance was extremely limited. For example, one facility had already been waiting a year to have air-conditioning installed.

Some darkrooms were small, and the CR unit could not be positioned without first removing sinks and existing processors. This meant that site work had to be completed as near to the installation date as possible so as not to interrupt access to imaging services. Facilities offering radiography may be located more than 100 km apart in this region. CR equipment was installed in an alternative location on the same site in some cases. Equipment was mounted on trolleys to facilitate relocation by local staff at a later date.

The site surveys identified that LAN access would be an issue. Work areas previously used as darkrooms generally had no access points. QH's Information Directorate provided a network map for all j.net sites at the start of the project. Six facilities were missing from the map, suggesting that the QH network did not service them.

The wide area network (WAN) connection to most sites had low bandwidth, typically less than 10 Mb/sec. Specialist network infrastructure advice was required to work out whether the existing network provided adequate bandwidth.¹ QH identified a requirement for network socialization testing to inform the required bandwidth for image distribution. Network socialization testing involves connection of the CR device in a test environment to establish how the transfer of images affects network performance and interaction with other network applications; this is required by the QH Information Directorate to ensure that new applications do not compromise existing mission-critical applications.

Small switches were purchased so that components of the CR system (reader, workstation, and printer) could be connected to each other in a LAN configuration. This helped to overcome immediate network issues and keep within project timelines. A decision was also taken to exclude WAN connection from the j.net project scope. Connection to the WAN and digital distribution of images became part of a wider ongoing radiology informatics program.

TESTING AND TRAINING

Acceptance testing is mandatory before a newly installed system is put into clinical use. QH provided training to the vendor engineer responsible for each installation so that he or she could perform the basic quality assurance (QA) procedure. The results of these QA tests were recorded. Images were forwarded to a QH physicist for further assessment and confirmation of acceptance.

Training for the licensed operators was complicated by the wide geographical distribution of sites. This meant that either the trainer or the operator had to make a lengthy journey to meet face to face. Most licensed operators had no previous knowledge of CR. Some had difficulty obtaining cover so that they could be released from their primary duties for training.

The low number of x-ray examinations performed at some sites made it all the more important for operators to be trained well and their skills reinforced (Figure 1). Data from one site indicated that just 12 patients underwent x-ray radiography over the course of a year.

A training plan was developed that incorporated an introduction to CR, onsite applications training provided by the vendor, and follow-up training with competency assessment.

The introduction to CR was ideally delivered by a local radiographer at a district site with similar equipment. Backup was provided by radiographers from Statewide Telehealth and Statewide Medical Imaging Support Service; these different divisions of QH provide services in remote locations. Local radiographers providing support for licensed operators were identified as part of the training plan and included in the follow-up training as “superusers.”

The applications training, which was delivered onsite by the vendor's application specialist, consisted of two days immediately following installation of the equipment and one day follow-up at a later date. A Telehealth radiographer assisted with this part of the training in some cases to help operators gain the necessary expertise for future competency assessments required by the Queensland regulatory authority for radiation matters.

The j.net project team created training documentation and PowerPoint presentations aimed specifically at licensed operators to supplement the vendor training manuals. Earlier experiences had demonstrated that training in smaller community hospitals requires a different perspective. ² The training guides developed were provided locally and posted on the QH intranet site to be available after project completion.

Practitioners providing radiographic and radiological services in rural and remote areas benefit from continuing education and support by radiographers.³ User support was provided by Telehealth radiographers, who were accessible by phone during installation and for some months after project completion. Although future support is essentially outside the scope of the j.net project, gaps were identified in the existing support model for licensed operators. Team members helped to redress this by providing input to the educational program of workshops organized by rural training units and the QH Skills Development Centre. Equipment for practical training was also installed at training institutions.

The greatest challenge by far was the transportation of staff carrying out onsite installation and training. Because some centers had limited accommodations, personnel needed to travel in and out on the same day. Access to hire car companies proved to be an issue in some remote locations.

Charter planes were used to reach many areas. Staff were dropped off in the morning, then picked up at the end of the day and returned to where they were staying.

All equipment was delivered by road. Weather affected access to some locations, causing delays in the installation schedule. Multiple methods of communication were used, including the establishment of a generic e-mail address allowing direct access to the project team. Project fact sheets were distributed via e-mail and in the post. Although most staff in QH have e-mail accounts, access to computers is limited at some facilities. Telephone contact was essential to confirm installation and training schedules.

PROJECT COMPLETION

The installation phase was completed within project timelines, with the final installation occurring at Croydon Hospital, north Queensland, on 23 June 2008. Use of local resources was pivotal in meeting project timelines. This aspect of the project involved identifying staff who were in the vicinity or paid regular visits to facilities.

All radiographers and licensed operators who had been involved were sent a survey. The response rate was 36% (120 respondents). Overall, 90% of respondents expressed satisfaction with the project outcomes, and many submitted positive comments. These included “The system is very easy to use and a vast improvement on the old one” and “We all love the CR images produced and the quality is outstanding” (Figure 2).

The high satisfaction rate reflects the quality of the project processes and the attention paid to the change management aspects of introducing new technology. This result appears to support the assertion that change can be managed effectively by paying careful attention to communication, planning, process evaluation, and training. Not only that, but users will accept the system and hopefully enjoy using it.⁴

Site visits played an important part in the planning and preparation project, as did the communication of project outcomes to staff. Clarification of the project's scope could have been improved. Many users were under the impression that the equipment would immediately let them transfer images to other QH sites. This was not the case.

Project stakeholders also identified concerns about the cost-effectiveness of the new technology. Cost savings when moving to a digital imaging environment typically occur through the reduced need for film, wet chemicals, and film storage and handling.^1,5,6 Health Service districts will, however, still have to purchase a certain amount of film and CDs for image distribution and storage, due to the delay in connecting to the LAN/WAN for image transfer. They will also be responsible for postwarranty servicing of the CR equipment.

Filmless radiology departments have reported a significant decrease in overall examination turnaround times, though the introduction of digital acquisition systems alone has not produced a significant reduction in average examination time.⁶ The move to CR must be recognized as the first step toward a filmless environment. In conclusion, QH now has digital image acquisition at all of its medical imaging sites. Rural and remote image acquisition sites are well positioned to take advantage of the digital imaging paradigm.

The disparity in health outcomes between the city and the “bush” is a recognized issue in Australia.⁷ Some sites are already able to move images across the network and access radiologist interpretations and/or specialist consultation. Work needed to establish full WAN connectivity for the remaining sites continues. Once this is complete, all of QH's image acquisition facilities will have equitable access to these specialist services that can make a pivotal contribution to clinical decision making and management.⁸