Digital Radiography

The accelerating growth of the digital radiography field has led to a new host of possibilities in the veterinary practice.

Conventional X-ray technology has been used for decades, virtually unchallenged and unchanged. Now the rapid evolution of digital X-ray options makes veterinary consumers ask what’s the right system for me? How do I store my images? Who do I make them available to?

About 25 percent of veterinarians use digital radiography equipment in their practice and 70 percent are expected to use the technology within the next five years, according to Idexx Laboratories of Westbrook, Maine. But the profession is divided when privacy enters the conversation, leaving some less eager to trust an outside company with the responsibility of storing images.

Veterinarians agree that determining what to do with picture archiving and communication systems, or PACS, is a big decision. PACS are servers dedicated to the storage, retrieval, distribution and presentation of images. They can stay under the owners’ roof or be placed in the care of an outside company.

While keeping images in-house solves privacy concerns, an off-site company takes responsibility for the images’ protection and can be a good way to protect records in the event of a fire or natural disaster.

“There are a small percentage of clients who educate themselves to the level required to make the right decision when it comes to selecting a complete digital system, including the networking aspect,” says Luke Nye, systems engineer for Illumipet, an off-site image storage company.

“Most utilize the guidance and recommendation the  company offers when making the final decision.”

Some cautious veterinarians prefer to maintain control of images and back up the images on CDs or external hard drives.

“The possibility for a privacy breech is very real with off-site storage,” says Victor Rendano Jr., VMD, Dipl. ACVR, Dipl. ACVR-RD, of eVet Diagnostics in Lansing, N.Y. “I think vets should control their own data to secure complete security.

“A recent acquisition of a digital radiography company by a large veterinary chain has veterinarians concerned about their medical record privacy,” Dr. Rendano says, voicing a concern often heard since VCA Antech of Los Angeles acquired Eklin Medical Systems of Santa Clara, Calif., in July. VCA merged it with its Sound Technologies to form Sound-Eklin of Carlsbad, Calif.

And in August, Idexx Laboratories of Westbrook, Maine, acquired VDIC of Clackamas, Ore.

The privacy concern is unfounded for several reasons, says Greg Stoutenburgh, director of marketing for Sound-Eklin.

“The terms and conditions of the image archival contract guarantee that only employees of Sound-Eklin, not VCA, have any access to stored data,” he notes. “This access is restricted to purposes including quality control, support and education, with anonymized studies.”

“With over 3,000 customers who have had access to this archive, not one has ever had any discrepancy or voiced concern about data security after installation. Further, information contained in the image headers cannot reasonably be used to obtain any sort of competitive advantage,” Stoutenburgh says.

“And lastly, to be a good veterinary neighbor, VCA has a strict policy against engaging in external marketing to consumers.”

Don Schofield, general manager of VDIC Telemedicine from Idexx Laboratories, says a lot goes into ensuring image security.

“Clients’ concern is heightened when the company they’ve been doing business with is suddenly under the control of another. It’s a natural reaction,” he says. “But we offer services that are accurate, private and allow quick account access.

“Radiography images can be so large that vets find they quickly run out of storage and they often don’t want to learn the technology to store everything. Off-site storage allows someone who knows technology to manage images, and lets vets focus on medicine.”

While the benefits of switching to digital radiography are readily seen at veterinary trade shows, from sales representatives and through lectures, the allure of a promising new piece of equipment often trumps the discussion on package details and equipment options. Every company will make its product appear the most appealing, but at the end of the day there is one major area that non-compliant companies fail to mention.

DICOM

Medical images are stored in an independent format, and the most common format for image storage is digital imaging and communications in medicine, or DICOM. Electronic images and reports are transmitted digitally via PACS, which eliminates the need to manually file, retrieve or transport film cases. PACS has the ability to provide access to images, interpretations and related data more quickly in part by eliminating the snail mail process.

PACS eliminates physical barriers that occur with traditional film-based image retrieval, distribution and display. While the traditional X-ray process involves film processing after capturing the image, PACS can allow the technician to see the image immediately.

“DICOM standards are essential when making an equipment purchase,” says Rendano, of eVet Diagnostics. “This allows data to be entered on the patient once, then stored for each subsequent image instead of re-entering data for each shot. If these standards are adopted by the company you purchase equipment from, companies can’t say, ‘We’ll interact with companies X and Y, but not Z.’ The images will be able to be shared with anyone who has a DICOM viewer.”

The American College of Veterinary Radiologists sets standards for PACS, which the experts say provides the best information for radiology competence—so finding a company that complies with DICOM is essential.

Storage Time

Off-site storage companies charge differently. While some charge per image, other charge per gigabyte or delete older images if you supersede your storage allotment.

“Cost varies by vendor,” says Bill Hornof, DVM, chief medical officer for Sound-Eklin. “It can be $1 or $2 per case, a monthly fee or cost per gigabyte. And as more data is stored, the cost goes up.”

An external hard drive can be purchased for less than $200 and used for in-house image storage. Those who use this technique say it isn’t a complex solution and can be a staff member’s responsibility.

“If a company that stores your images goes out of business, what happens to your records?” Rendano asks. “At that point, there’s little concern on their part for fidelity of information. Doing it yourself in-house means you control your data.”

Practices that perform many X-rays benefit the most from off-site storage, Dr. Hornof says.

“Larger practices and referral practices are exposed to a wide variety of radiography images and may want to use off-site storage in addition to keeping an in-house record,” Hornof says. “This protects the practice in the case of computer malfunctions or a hurricane. Through DICOM, you can have the images automatically routed to an off-site backup.”

Illumipet’s Nye says the cost of in-house image maintenance can add up and the amount of storage needed plays a role in the expense.

“Paying a staffer to manage your images can become a crippling cost,” Nye says. “The most crippling occurrence is thinking that your data is backed up but when disaster happens, you find that you can’t retrieve the data because it wasn’t properly maintained.”

While radiologists say digital radiography in general has been positive for the field and the industry, it opens a point of concern that so far has been largely overlooked: While instantly seeing an X-ray image does decrease the incidence of re-shoots and saves time, it also increases the veterinarian’s willingness to radiograph more areas of the body.

“The veterinarian is willing to shoot more images to explore possible additional areas that could be contributing to the condition being examined,” Rendano says.

“I wouldn’t be surprised if radiation exposure became a big concern on the technician front in the future. I receive cases that have as many as 39 different images on the same animal. This is something that wouldn’t happen with traditional X-ray techniques.”

Rendano notes that PACS helps speed the process by getting images to referral vets faster and, once the specialist evaluates the images, it gets back to the practitioner faster. But he says too much emphasis on speeding the process is just “sales talk.”

“When you send an X-ray for evaluation, sending it STAT will get you a faster reading,” Rendano says. “Keep in mind [a specialist’s] evaluation process is the same as always. Received images go into a queue that is first come, first served.”


What to Ask a Sales Rep

“Most veterinarians don’t have a lot of knowledge of PACS,” says Fotine Sotiropoulos, marketing manager of digital imaging for Idexx Laboratories. “Consider asking some questions before making a purchase.”

• Ask whether the digital radiography system includes full PACS.
• Ask about the cost of additional software seats.
• Ask how the software is supported and by whom.
• Ask whether updates are offered and what they cost.
• Ask about light/mini PACS. 
• Ask about full PACS.
• Read all the terms and conditions.


This article first appeared in the November 2009 issue of Veterinary Practice News.

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