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Going Digital?
This retinal practice tells how a well-planned switch to digital imaging can create numerous benefits.
BY KATHLEEN SALTER, COA, AND STEWART A. DANIELS, M.D.
So your practice is considering converting your photography department from strictly film-based imaging to digital. Now is a great time to make that move. Even famed movie director George Lucas has conceded that digital imaging has many practical advantages over film: He shot the latest installment of the "Star Wars" series digitally.
Our retinal practice doesn't have much in common with a movie studio, but, as we'll explain in this article, by "going digital" we're now able to operate more cost-effectively, while at the same time bringing real benefits to our patients. Here are a few reasons we switched:
Immediate image availability. This advantage alone has enabled us to deliver treatment more quickly and speed patient flow.
With film, we were forced to have most of our macular degeneration patients return for photodynamic therapy treatment, transpupillary thermotherapy or argon laser on another day, or even another week after the pictures were obtained. Now, we can usually obtain the images and provide treatment all in one visit. As a result, our doctors can spend more time with the patient without the added time of follow-up phone calls.
Reduced overhead. By closing our darkroom, we've eliminated the costs associated with chemistry, film and employee overtime for developing. This has freed up much more room in the office for improved space allocation. In addition, the instant images provided by our digital system enable us to train new photographers more quickly.
Efficient use of images. Because we display all digital images on a monitor, we print them only when we need to send a report to a referring doctor. We can store and retrieve digital images easily because of the relational database structure and archiving ability. We're then able to send them to other medical offices or facilities as printouts or Web-based files.
Improved patient education. Because of the large monitors in our photo room and exam rooms, our visually compromised patients can now "see" their test results immediately, and are able to understand what their doctor is referring to.
The Monitor is Key
The core idea of digital imaging is to go paperless. It's a hard concept to grasp at first, but you soon learn to give up the paper and go for the monitor. Treat from the monitor. It's your friend.
But before you make the big decision to go digital, step back, and evaluate the specific needs of your practice. Converting from film to digital may seem painful at first, but with a little patience and careful planning, you'll be glad you made the switch. Here, we'll help guide you in making the film-to-digital conversion successfully.
Start with Space Planning
Walk into the room of your photography department and take a good look around. How much space do you truly have for your capture station, fundus camera, supplies, photographer, patient and patient's family members?
If there's only room now for your photographer, existing camera and patient, you need more space. Remember, you'll no longer need a darkroom, so try to combine the two rooms to convert the space to a digital imaging department.
Consider the view your photographer will have of the monitor while shooting pictures. Your photographer must be able to comfortably view the monitor and have access to the mouse and keyboard while simultaneously acquiring the images. The mouse, keyboard and monitor can't sit 6 feet away on the other side of the room.
Planning the placement of the camera and capture station must also allow for venous access on either side of the patient. Simultaneous easy viewing of the capture station monitor by the physician can allow for immediate evaluation of adequate documentation of the pathology in question, and aid in the education of new photographers.
Facilitate Office Flow
Discuss with your photographers where and how you'll treat each patient and review the study after their images are obtained. How you'll use your images and where you'll treat your patients will decide how many review stations you'll need for your practice.
You'll need at least one review station for your laser treatment room. Most practices will need more review stations to allow the physician to dictate, and to review angiograms with patients in any exam room.
Counter space in your exam and laser rooms is probably limited. Our office was able to solve that problem by getting flat-panel LCD monitors that can mount to the wall, or you can mount keyboard drawers that pull out when needed, preserving precious counter space. We have 19-inch ultra-sharp flat-panel monitors in the exam rooms, where the large screen size and wider viewing angle is very helpful in the presentation of angiography results to patients and family members. We have a less expensive, standard 17-inch space-saving flat-panel monitor with a smaller viewing angle in one of our laser treatment rooms. This is adequate for treatment, where one person is primarily viewing the station from straight ahead. Wireless keyboards and mice reduce the clutter on the countertop.
Choosing a Digital System
Many companies claim to offer the latest and best in digital technology. Before you walk the Academy floor and get dizzy from the spectacular mega-high resolution images they display on $10,000 plasma screen monitors, go to your vendors armed and ready to discuss the following points:
Your annual imaging volume. This total will not only help in calculating your return on investment, but also help explore networking and storage options for your digital images. The network for your capture and viewing stations must be planned and cabled in advance.
Your photography room and each room that has a review station must be at least Category 5 cabled. The network and storage solutions you choose will essentially depend on patient volume in your practice and how many satellite offices you have. Your capture station can act as a server for your local area network in one office, but your hard drive could be filled within a year or two, depending on your practice volume. If you have more than one office that will have digital angiography, you'll need a server and digital subscriber or T1 lines connecting all your offices in order to view images captured in one office in another.
Some vendors offer online viewing packages of these images, and using encrypted software, allow access through your web browser to view all images via a password. It's important to ask each vendor how their system will archive images, and in what format. If all the images are stored with proprietary software, your angiograms and fundus photos may not be viewable in the future if the company changes database architecture or goes out of business. If any of the images are compressed to save storage space, you may lose image quality. It's worth your time and money to consult an IT professional before attempting to network multiple offices.
Not long ago, I asked a physician in our practice for a word document file that I needed in a digital a format, not a hard copy. No problem, he said, I'll bring you the disc tomorrow. The next day he handed me a 5-inch soft floppy disc. Just what did he think I was going to do with that old thing? It would make an excellent coaster, possibly a good Frisbee alternative for some office Olympics, but no one had a computer with a drive that would read an obsolete format. That went the way of the dinosaur in just a matter of a few years. I remember eight-track tapes too, and thought they were pretty cool for the time, but do you have any now?
Your archiving must keep with the times and look toward the future, not become impossible to retrieve 5 years down the road. Drive makers have to devote engineering time and money to develop each function in their product. Eventually, data CD-Roms may be forced out by data DVDs or other storage media. That means drive makers will support CD-Roms for a while during the transition. But they'll only support them as long as they think they have to. And don't assume that DVD storage is the best way to go for the future. Explore all of the available options.
New system or add-on? Evaluate your current fundus camera. If you're having trouble getting parts and technical support for maintaining this camera now, check out a fully integrated digital system with a new camera. Check out any new fundus camera thoroughly at each angle of view, and evaluate images captured with digitally enabled cameras at varying resolutions.
Some companies sell digital systems that will fit on to your existing camera. If you go that route, make sure that if you have to buy a new fundus camera in the future, your digital system will still be compatible with the new fundus camera. You don't want to be in a position where you have to make modifications to a new fundus camera in order for the capture system to operate. These changes can sometimes violate the manufacturer warranty of the fundus camera itself.
Indocyanine green angiography. Indocyanine green (ICG) angiography is of some value for specific retinal and choroidal diagnoses. ICG will fluoresce with invisible infrared light, which requires a specially configured fundus camera sensitive to these wavelengths.
Older fundus cameras don't have the appropriate infrared-sensitive optics needed to image ICG, or the exciter and barrier filters matched to block all light except infrared. The specially configured fundus camera employs filtered light from a Xenon flash lamp to excite ICG dye. Then, a digital-charged coupled device (CCD) camera is used for image recording.
The infrared wavelengths have the ability to penetrate the retinal layers, making the circulation in deeper layers visible when photographed with an infrared-sensitive camera. This option costs more than fluorescein-only capability. Assess your needs for this feature. We have only one ICG-capable camera for our multi-office practice, and find this adequate.
Participation in clinical trials. The Reading Centers, study sponsors, FDA and the new HIPAA regulations have specific requirements regarding exporting digital images. Ensure that the capture system you're considering purchasing has already been approved by the Reading Center you use. Investigate what format these images need to be in to be exported and make sure the software you're considering has this capability. The software should be Digital Imaging and Communications in Medicine (DICOM) compliant.
The DICOM standard was created by the Radiological Society of North America (RSNA) to develop a common protocol that could be used in the distribution and viewing of digital medical images, such as CT scans, MRIs, and ultrasound. Part 10 of the standard describes a file format for the distribution of images. Most people refer to image files that are compliant with Part 10 of the DICOM standard as DICOM format files. A single DICOM file contains both a header (which stores information about the patient's name, the type of scan and image dimensions) as well as all of the image data. DICOM is the most common standard for receiving scans from a hospital.
Every manufacturer should have a conformance claim for its products that support DICOM. This statement must be made according to Part 2 of the standard. Most medical imaging companies should either have conformance statements or be well on the way to developing them.
Software integration needs. Thoroughly evaluate the software and database for each system you consider. Does your practice perform photodynamic therapy? If so, then the software should calculate not only the body surface area for your patient, but it should also provide the drug dose for Visudyne after you enter the patient's height and weight into the database.
Will you need to measure lesion size by disc area or disc diameter? The software should be flexible enough to do both. Additionally, ensure that if there are any modifications to an individual image, possibly to sharpen or manipulate the captured data in any way, the original image will always be saved to the patient's file and not replaced by the modified image, maintaining the integrity of the initial captured image.
The software should be easy to navigate so your staff can learn to export the data obtained for lectures, teaching, telemedicine, and custom reports. What are the file options for export? You should be able export either individual images or entire studies as a JPEG or TIFF, and a DICOM as needed. The search mode of the database should allow for pinpoint accuracy to pull up patients by name, date, referring doctor or diagnosis. The search mode should also be easily modified to fit any other criteria your group uses to retrieve information.
Need for printed reports. The basic idea of converting to digital imaging is to eliminate paper. When our practice first converted from film to digital, one physician still couldn't give up the habit of reading from hard copy. Eventually, it sunk in that you treat from the monitor, not the paper, and now he never asks for prints.
The quality of the image that gets printed isn't based on the resolution of the monitor and the camera, but on the ability of the printer itself to reproduce high-quality photographic appearance. Your everyday ink jet printer isn't capable of this quality, yet is it sufficient to send a report that gets your diagnostic and interpretive information across? Most practices wouldn't consider buying a $10,000 sub-dye printer just to send reports to their referring physicians, or to file in their own charts.
Review the cost per print by comparing different printers on photo-quality paper and then decide which printer is right for you. The ease with which you can generate these prints and custom reports varies depending on the software. Ask your vendors for a full demonstration of their custom reports, and ask if there's an option for easily creating letters to referring doctors.
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Making the Best Choices
If you conduct your research before contacting vendors, you'll be able to make an educated decision concerning your digital imaging needs more quickly.
Ultimately, your photographers are the ones acquiring these images for you to treat your patients. Their input and feedback regarding cameras and software is crucial. The images to which you're exposed during the Academy convention or any other meeting are obtained under optimal conditions with perfectly clear media and a cooperative patient. These perfect images aren't truly reflective of an everyday ophthalmology clinic.
It's important to demo the software for an adequate amount of time so you can ascertain the image quality of the average patient seen in your office on a daily basis. An adequate demonstration period should also give all your photographers an equal chance to "test drive" the equipment.
Finally, have fun in being introduced to exciting technological advances that can significantly improve your ability to practice high-quality and efficient ophthalmic care.
Kathleen Salter, COA, is a practice administrator, study coordinator and retinal angiographer for Bay Area Retina Associates, a multi-office private practice based in northern California. The practice recently purchased a Zeiss FF450plus IR camera with Zeiss Visupac Digital Imaging and Archive Management software. Salter is also an instructor and lecturer for the Ophthalmic Photographer's Society, JCAHPO and the American Society of Retinal Specialists. Stewart Daniels, M.D., is a partner at Bay Area Retina Associates and is on the clinical faculty at the University of California, San Francisco, and California Pacific Medical Center.
Ophthalmic Digital Imaging Comes of Age
By Jerry Helzner, Associate Editor
A decade ago, ophthalmic digital imaging was in its infancy. A small number of forward-looking ophthalmic photographers and software designers believed that digital technology had significant potential in eye care, though producing the images was expensive and the quality didn't come close to rivaling film.
"Back in 1992, I was working with a retina practice that was one of the early adopters of digital imaging technology," recalls Lon Dowell, CRA, who's now product manager for ophthalmic imaging and lasers at Carl Zeiss Meditec Inc. "The compact discs we used to store the images were about $15 each and it cost about $1.50 to produce a printout. Today, a compact disc goes for under a dollar and a printout costs about a quarter."
Peter Van Houten, M.D., who's in private practice at East Carolina Retina Consultants in Greenville, N.C., and clinical professor of ophthalmology at East Carolina School of Medicine, was also a digital imaging pioneer.
"I was going into practice in 1993 and I knew that with film I'd need a photographer, a darkroom and added time for film processing," he recalls. My budget was tight and I had always been interested in computers, so I found a little company called Midwest Ophthalmic Imaging that had put together a digital system consisting of a Kodak adaptation of a Nikon F-3 camera with an imaging chip, some software and a monitor. I became the first ophthalmologist to buy their system."
Dr. Van Houten says even that very early system provided his practice with major advantages over film.
"I could show the patient the pictures, point out the problem and laser the leaking blood vessels all in one visit," he notes. "Essentially, I was able to offer one-stop shopping.
Digital Gains Ground
As the costs associated with digital imaging gradually came down, the quality of the technology used to produce, enhance and store the images continued to improve.
"By the mid-1990s, we were able to quickly produce robust, cost-effective digital images," says Greg Hoffmeyer, senior ophthalmic photographer/supervisor at the Duke University Eye Center in Durham, N.C.
"The resolution we achieve now with digital images is very close to film. You can't even tell the difference," says Hoffmeyer. "And digital imaging represents a great advance in information management. It's a giant step forward in file keeping, charting and the immediate transfer of information."
Today, the cost/quality equation of film vs. digital imaging has tilted in favor of digital. And those who have a glimpse into the future of ophthalmic imaging see digital technology emerging as the clear winner.
"It's only recently that digital systems have rivaled film," says Dowell, "but what we'll see in the future in digital and optical design will amaze people."
Some experts in the field believe that future improvements in digital imaging will eventually lead to image analysis that approaches automated diagnosis.
"I believe that as resolution increases and prices decrease we'll no longer have a need for film-based systems," adds David MacLellan, director of sales and marketing, Nidek Technologies America. "But although digital imaging in general has taken giant steps forward from a commercial standpoint, this advance is somewhat difficult to keep up with from a development standpoint in ophthalmology. It's not as easy as just attaching a camera and storing an image. There's timing, chip sensitivity and a number of other small details that help create a high-quality image for medical use."
MacLellan believes digital imaging has reached the point where it's a standard need in any ophthalmology practice, but he'd like to see the wider adoption of electronic medical records to enable digital technology to reach its full potential.
"Until electronic medical records systems are more widely accepted and utilized, there will be gaps with storage, printing and taking full advantage of the technology," says MacLellan.
Expanding the Digital Realm
Given the current quality of ophthalmic digital images and the savings in time and money that can be achieved by "going digital," the use of digital images has been expanding from its initial base of retinal specialists to other areas of ophthalmology.
For example, for under $5,000, ophthalmologists can now combine a slit lamp, a specialized beam splitter with adapter and a consumer-grade digital camera to produce large, high-resolution images of the anterior segment. With these images, ophthalmologists can better document the progress of treatment for conditions such as uveitis or corneal ulcers, or track healing following refractive surgery.
"When you're talking about the anterior chamber, I see digital imaging as a useful tool for documentation and patient education, but not for diagnosis," says Dowell.
"Anterior segment doctors just don't rely on pictures as much as retinal specialists," adds Hoffmeyer. "But the digital images are great for charting changes over a period of time. You can show the patient exactly what's happening in the eye."
"By showing a patient a large, high-resolution digital image that clearly illustrates his problem, you're really providing him with an opportunity to give informed consent for a specific treatment," adds Dr. Van Houten. "From a liability standpoint, that's one of the underrated advantages of digital imaging."
Ophthalmologists who are willing to spend approximately $50,000 for a digital confocal microscope can obtain a huge amount of anterior segment information, according to Stephen D. Klyce, Ph.D., professor of ophthalmology and anatomy/cell biology at the Louisiana State University Eye Center in New Orleans.
"With digital confocal microscopy, the magnification can be as high as 500x," says Dr. Klyce. "And with so-called "zero lux" high light-sensitivity digital cameras, one can image the fine details of corneal nerves, LASIK interface debris, fungal infections, acanthamoeba trophozoites, endothelial size and shape, and a host of other facets of the corneal fine structure and pathology."
Dr. Klyce believes that as the price of digital confocal microscopes continues to drop, the technology will find its way into more and more clinics because it offers a higher level of diagnostic capabilities than the familiar slit lamp.
Improving Glaucoma Monitoring
Though Greg Hoffmeyer believes that color stereo fundus photography is still the "gold standard" in monitoring glaucoma progression, he says recently introduced digital fundus cameras capable of taking digital photos in stereo represent an advance.
"Ophthalmologists wearing special 3-D 'shutter glasses' are able to view these photos as huge, stereoscopic images, which helps them greatly in assessing the amount of optic nerve head cupping," he says.
And while the nerve fiber layer analyzers that are being increasingly used to detect and monitor glaucoma essentially represent a whole new technology for looking at the eye, they are also digital. Thus, they, too, are a part of the digital revolution.
Small Practices Benefit Most
For solo or smaller general ophthalmology practices that don't have a skilled ophthalmic photographer on staff, digital imaging systems and/or digital nerve fiber layer analyzers such as the Stratus OCT, HRT II, RTA and GDx can be the answer from both a cost-effectiveness and quality standpoint.
"Smaller practices are able to more easily make the switch to digital imaging," says Hoffmeyer. "For maybe $80,000, a small practice can invest in a digital system that will soon pay for itself by saving many hours for techs and doctors. The major eye centers have to make a huge investment of $500,000 or more to digitize, and those kinds of decisions aren't always made quickly."
If you do choose to go digital, experts in the field are almost unanimous in recommending that you choose a vendor that will be around to provide long-term service and support.
"Several smaller or startup companies are getting into the business of putting together digital imaging packages," cautions Dowell. "Be certain the system you purchase is designed to the rigorous standards mandated for medical devices by the FDA. These companies are likely to be more stable and attentive to the customer, and should be around for years to come."
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