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

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

AJR:179, July 2002 33


and additional requirements for administra-
tive, supervisory, and educational activities.
With the advent of computer technologies
in the imaging department, some of these
operational inefficiencies can be addressed
through the combined use of computed radi-
ography, hospital and radiology information
systems, and picture archiving and commu-
nication systems (PACS). This study was
undertaken to objectively quantify the effect
these technologies have on technologist ex-
amination times. The study focused on the
performance of general radiographic exami-
nations, which constitute 60–70% of a hos-
pital’s imaging department volume [8]. By
analyzing work flow using time–motion
studies, we attempt to better understand the
complex relationship between these digital
systems and technologist productivity. This
information can assist imaging providers
with objective measures for cost–benefit
analysis when contemplating a transition to
filmless imaging.
Materials and Methods
Prospective time–motion studies were per-
formed at three medical centers during a 1-week
Film-Screen Radiography (Fort Howard)
1. Place exposed film in pass box.
2. Develop film images, remove film from cassettes,
place film images into conventional processor,
refill empty cassettes with new film, replenish film
bin if empty.
3. Complete paperwork (historical and demographic
information).
4. Remove film images from conventional processor.
5. Review images for quality control.
6. Annotate images and obtain repeated images as needed.
7. Collate film images and paperwork.
8. Pull patient master film jacket from file room.
9. Pull pertinent comparison film images and reports
from film jacket.
10. Submit unreviewed films 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
Reiner and Siegel
period. Examination time was defined as the time
from patient arrival in the examination room to the
time completed images were ready for radiologist
interpretation; this period was timed by indepen-
dent observers using a stopwatch (Fig. 1). Any de-
lays or interruptions during the course of each
study were recorded and included in the data anal-
ysis. Data were recorded during routine weekday
hours of operation, and technologists were aware
that a timing study was being performed.
The two commonly performed types of radio-
graphic examinations chosen for evaluation were
chest (two views) and orthopedic examinations of
the spine (three to five views). Portable examina-
tions were excluded from the study because of the
large variability in work flow steps for these stud-
ies among and within the three facilities. Conven-
tional film-screen radiography was performed at
two of the three study institutions (Fort Howard
and Philadelphia Veterans Affairs Medical Cen-
ters), and filmless operation using computed radi-
ography was used at a single study institution
(Baltimore Veterans Affairs Medical Center).
For the film-based operation at the Fort Howard
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-
based operation at the Philadelphia center, film-
screen cassettes were developed using a daylight
processor (ML 700; Eastman Kodak). For the
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 (Philadelphia)
1. Place exposed film cassettes into
daylight processor.
2. Complete paperwork (historical and
demographic information).
3. Remove film images from daylight
processor.
4. Refill empty cassettes with new film.
5. Review processed film images for
quality control.
6. Annotate images and obtain repeated images
as needed.
7. Collate film images and associated
paperwork.
8. Take completed study to file room
for radiologist interpretation.
filmless operation at the Baltimore center, com-
puted radiography was performed using a plate
reader (AC-3; Fuji Medical Systems, Stamford,
CT) that is interfaced with the hospital and radiol-
ogy information systems (Veterans Health Infor-
mation Systems and Technology Architecture) and
a commercial PACS (General Electric Medical
Systems, Milwaukee, WI).
The prospective time measurements obtained at
the study institutions were correlated with the na-
tional standards for workload in a film-based de-
partment [9]. The two film-based institutions were
chosen because of their similarities in technologist
staffing, patient demographics, and location. The
Philadelphia and Baltimore centers are also com-
parable in examination volume, modality mix, and
presence of a strong academic affiliation.
Statistical analysis was performed using both
one- and two-way analyses of variance to evaluate
differences in technologist examination time
among the three study institutions, between film-
based and filmless operations, and between the
two types of radiographic examinations evaluated.
Results
Prospective time measurements revealed
significant time savings for filmless operation
(Table 1) for both categories of general radio-
graphic examinations evaluated ( p < 0.001).
Filmless Computed Radiography
(Baltimore)
1. Place computed radiographic
images into plate reader.
2. Enter unique case information
into computer and open
electronic folder for patient examination.
3. Review computed radiographic
images on PACS workstation
and edit as needed.
4. Verify examination electronically and
close folder.
AJR:179, July 2002
 Technologists’ Productivity When Using PACS
For posteroanterior and lateral chest radio-
graphic examinations, significant differences
were found when comparing the filmless
study site with the two film-based sites ( p <
0.001). A mean time savings of 3.4 min
(31%) was observed when comparing exami-
nation times at the film-based Fort Howard
center with those at the filmless center. A
greater mean time savings of 6.6 min (47%)
was observed when comparing the film-based
Philadelphia center with the filmless center.
The mean examination time required for a
posteroanterior and lateral chest study at the
Fort Howard center was similar to the na-
tional norm [9], which is approximately 10
min, whereas the mean examination time at
the Philadelphia facility was substantially
longer than the national average. The exami-
nation time at the filmless medical center was
substantially lower than the national average.
The difference in the mean examination
time for imaging the spine was also signifi-
cant when comparing film with filmless op-
erations ( p < 0.001). A mean time savings of
5.1 min (37%) was observed when compar-
ing film-based operation at the Fort Howard
center with filmless operation at the Balti-
more center. This mean time-saving with
filmless operation was significantly greater
when comparing the Baltimore and Philadel-
phia centers, with a 12.0 min (58%) savings.
The examination times from the film-
based institutions are comparable to the na-
tional norms, which have been reported as
ranging from 11 to 15 min for a three-view
cervical spine study, 15–22 min for a five-
view cervical spine examination, 8–15 min
for a three-view lumbar spine study, and 20–
30 min for a five-view lumbar spine exami-
nation. The lower ends of these ranges refer
to ambulatory patients, whereas the upper
ends refer to nonambulatory patients. The
combined examination time for all spine
studies at the filmless Baltimore center was
at the bottom of the range for a national
three-view lumbar spine study and below
TABLE 1 Technologist Examination Times When Using Film-Screen Radiography Versus Filmless Computed Radiography
Type of No. of
Fort Howard Center
Examination Views
Mean Time (min)
Chest 2 10.8
Spine 3–5 13.9
AJR:179, July 2002
the national range for a three-view cervical
spine study or a five-view cervical or lumbar
spine examination.
Discussion
Although time–motion analysis in tech-
nologist performance of radiographic exami-
nations is a valuable exercise, it represents
just a single phase in the complete radiogra-
phy work flow process, which begins with
the examination order and ends with the de-
livery of the final radiography report. A pre-
vious analysis of this work flow process
during film-based operation at the Baltimore
center enumerated 59 individual steps [10],
underscoring the relative inefficiency of most
film-based imaging departments and the ne-
cessity for work-flow optimization.
We found a substantial difference in the
number of work-flow steps for technologists
when comparing examination times for film-
based and filmless operations (Fig. 1). After
the technologist acquires the radiographic
images, an additional seven to 14 steps were
required for the film-based facilities in our
study, depending on the individual depart-
ment’s technology, work flow, and ancillary
personnel. Using a daylight processor in lieu
of a conventional processor or assigning
these tasks to a darkroom aide, a technolo-
gist can eliminate the four steps related to
image processing. At the same time, an ad-
ditional three steps can be avoided by trans-
ferring all the responsibilities for image and
report collation, transport, and hanging to
file room staff. Although this transfer of re-
sponsibilities can result in improved tech-
nologist productivity, it creates additional
work for and diminishes the productivity of
other staff members. Regardless of whom
the work is assigned to, it still must be com-
pleted in a film-based department and re-
sults in operational inefficiencies.
Filmless operation results in a reduction of
these 14 steps to four steps without the trans-
Examinations Using Film-Screen Radiography
Philadelphia Center Both Centers
No. Mean Time (min) No. Mean Time (min)
146 14.0 173 12.5
53 20.8 160 19.1
fer of additional responsibilities to other im-
aging department staff members. The net
effect on improved operational efficiency is a
substantial reduction in examination times
(Table 1). Thus, using computed radiography
and operating in a filmless mode save a sig-
nificant amount of technologist time.
In a film-based department, technologist
work flow typically consists of responsibili-
ties that overlap with those of clerical and
film library staff. Technologists are typically
asked to perform functions that involve film
collation and distribution. These additional
steps were not fully accounted for in our
study design, which recorded the interval
from the time the technologist greets the pa-
tient to the time the images became available
for review in the film library.
In the case of filmless operation with
computed radiography, each examination
ended and the timer stopped timing the ex-
amination once the images became available
on the PACS for review by radiologists and
clinicians. However, for the film-based oper-
ations, examinations ended after the tech-
nologist had collated the images and
paperwork with the hard-copy film jacket
and had returned the entire file to the film li-
brary. Although a technologist’s responsibil-
ities in a film-based environment often
involve these additional steps, we did not
time these steps for our study. This omission
may have resulted in the underestimation of
the time-savings associated with filmless op-
eration. Moreover, we did not record the ad-
ditional time required for film-room staff to
make the images available for interpretation
by radiologists or review by clinicians be-
cause the focus of our study was on technol-
ogist productivity.
From the results in Table 1, several obser-
vations that are attributable to the unique
characteristics of the study sites can be
made. The film-based Fort Howard center is
an affiliate of the Maryland Veterans Affairs
Healthcare System, largely serving a less
Examinations Using Filmless
Computed Radiography at the
Baltimore Center
No. Mean Time (min) No.
319 7.4 185
213 8.8 160
35

acute, ambulatory outpatient population. Be-
cause patient populations differ at the two
film-based institutions, technologist exami-
nation times also differ: examination times
at the Fort Howard facility are shorter than
those at the Philadelphia facility, which
serves a mixed inpatient and outpatient pop-
ulation. Many of these inpatients are less
ambulatory and are consequently more diffi-
cult to position for the technologist perform-
ing the study. The patient profiles of the
Philadelphia and Baltimore centers are simi-
lar to one another; therefore, times from
these two centers present a more accurate
comparison between film-based and filmless
imaging operations.
The musculoskeletal imaging studies
were heterogeneous, both in terms of the pa-
tient populations and specific types of exam-
inations. For ambulatory patients, who
predominate at the Fort Howard facility, the
examination times tended to be shorter be-
cause of the relative ease in positioning the
patient. In addition, these examinations were
typically requested on a nonemergent basis
for chronic conditions, such as lower back
pain. On the other hand, a larger percentage
of the orthopedic examinations at the aca-
demic facilities (Baltimore and Philadelphia
centers) were of nonambulatory patients and
were urgent in nature.
Both of these factors tend to be associated
with greater technical difficulty for the technol-
ogist, resulting in the expected increased exam-
ination times. These differences in patient
population and ambulatory status are addressed
in the national benchmarks, which illustrate the
major differences in examination time between
these different patient populations.
One of the limitations of our study was the
relatively small sample size for each individ-
ual category of examination studied, which
precluded a detailed analysis of ambulatory
and nonambulatory patients or of a specific
anatomic region (e.g., cervical vs lumbar
spine). In spite of the sample size, however,
significant differences for the examination
categories were observed for all three study
sites evaluated.
In addition to the use of computed radiog-
raphy and a filmless mode of operation, the
use of a radiology and hospital information
system and the degree of integration with
computed radiography and the reliability of
these systems are critically important to
work-flow optimization. The hospital and ra-
diology information systems can be used to
improve work flow in patient registration;
36
Reiner and Siegel
examination ordering, scheduling, and track-
ing; image management; reporting; billing;
and statistical analyses.
A number of specialized integration en-
hancements, such as a Digital Imaging and
COmmunications in Medicine (DICOM)
modality work list, are available to further
augment technologist productivity. The use
of this feature can markedly reduce errors in
patient and study identification and can re-
sult in automatic, more rapid entry of pa-
tient information into the computed
radiography system. For example, another
study evaluating CT transmission failure
rates in a digital imaging department de-
scribed an initial failure rate of 8% [11]. Of
these transmission failures, 69% were the
direct result of human error, specifically
data entry errors. These errors caused sig-
nificant time delays for the technologist.
With the advent of the modality work list,
transmission failure rates decreased by
56%, resulting in enhanced operational effi-
ciency and technologist productivity [11].
Another software enhancement, the per-
formed-procedure step, can be used to further
increase operational efficiency by notifying
the hospital information system automatically
of examination status information. The auto-
mation of these processes, which were previ-
ously performed manually by technologists,
improves work flow, reduces transfer error
rates, and minimizes technologist fatigue.
Fatigue and stress seem to play a surpris-
ingly important role in technologist produc-
tivity, but these issues have been largely
ignored in the radiology literature. Two other
studies found in the film-based radiology lit-
erature suggested that up to 20% of a technol-
ogist’s examination time is attributable to
stress and fatigue [7, 12]. After transition
from the film-based to filmless operation, us-
ing computed radiography and PACS, tech-
nologists reported reductions in perceived
levels of stress and fatigue [13, 14].
The concept of job-related stress takes on
even greater importance in the current imag-
ing environment because of the increasing
shortage of qualified radiology technologists.
According to data from the American Soci-
ety of Radiologic Technologists (McElveny
C, personal communication), the number of
first-time technologists taking certification
examinations in radiography decreased by
49% between 1994 and 2000, with a de-
crease in the number of technologist training
programs of 19% over the same time period.
The Bureau of Labor Statistics estimates
50,000 additional radiology technologists
will be needed by 2006 (Devereaux K, per-
sonal communication). As the shortage of
technologists increases, work demands and
stress will continue to increase, potentially
diminishing technologist productivity.
A number of potential improvements can
address technologists’ increasing stress levels
and reduced productivity. As previously dis-
cussed, work-flow optimization is a critical
objective and can be further enhanced by
software developments, which continue to re-
duce the number of manual steps required in
the processes of data entry, image acquisition,
review, and processing. Greater distribution
of computed radiography plate readers
throughout the medical enterprise can further
reduce technologist travel time to and from
the sites of image acquisition.
Areas of high volume, such as emer-
gency departments, intensive care units,
and outpatient clinics, should have dedi-
cated plate reviewers to facilitate faster im-
age processing. An industry response to
this need has been the development of com-
puted radiography systems with in-room
plate reviewers. At the same time, newer
digital technologies are available that elim-
inate the need for cassettes, further reduc-
ing the number of steps required for
technologists and enhancing work flow.
These newer technologies include direct
(flat-panel) radiography and cassetteless
computed radiography. Recently published
studies [15–17] have reported improvement
in work flow with the use of these in-room
digital systems.
The transition from use of film-based to
filmless technologies in an imaging department
offers tremendous potential for work-flow re-
design and, consequently, improvements in op-
erational efficiency for technologists in the
performance of general radiographic examina-
tions. Although filmless operation at the Balti-
more center was associated with substantially
lower examination times than the two film-
based facilities or with national benchmarks,
we believe that additional improvements are
possible with the use of in-room radiography
systems and increased system integration. As
imaging departments become increasingly inte-
grated with the rest of the health care enterprise
using tools such as the DICOM modality work
list and the performed-procedure step, technol-
ogists in both film-based and filmless depart-
ments will likely continue to become more
productive without concomitant increases in fa-
tigue and stress.
AJR:179, July 2002
 Technologists’ Productivity When Using PACS

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AJR:179, July 2002 37