Editor's note: This is the second part of a three-part series that looks at the University of Texas Medical Branch at Galveston's transition from a film-based medical imaging system to a fully digital system. Here, ADVANCE looks at the training involved in the facility's decision to go digital.

Leonard Swischuk, MD, acting chairman of the radiology department at the University of Texas Medical Branch (UTMB) at Galveston, decided to usher the radiology department into the 21st century in 1998 by embarking on a five-year project to create a fully digitized imaging facility. The transition would mean an enormous economic savings for the hospital, while also virtually eliminating film loss and providing real-time communication between referring physicians and patients.

Today, with nearly $10 million dollars invested, the project is more than 99 percent complete, but Dr. Swischuk and Raul Reyes, RT(R), director of radiology services at UMTB, admit the transformation encountered its share of bumps along the road.

"Anytime you introduce change, there's going to be a certain amount of reluctance before accepting any type of new technology," Reyes says.

Educating the masses

According to Antonio Garcia, industry analyst for consulting firm Frost & Sullivan, the top two impediments to hospitals that want to make the digital transition are education and cost. Though many of the forums at conferences such as RSNA and SCAR have raised the level of awareness among radiologists and radiology administrators on digital radiography and PACS technologies, last year most U.S. hospitals were not operating in the digital realm, according to Frost & Sullivan.

Roughly 71 percent of hospitals in the country have 200 beds or less, and of those only 12 percent of hospitals with 200-299 beds implemented some type of PACS technology in 2002, while only 5 percent of hospitals with 100-199 beds, had made the transition, according to Frost & Sullivan.

"You're not going to create demand, awareness or growth unless people know what it is," Garcia says.

Dr. Swischuk and Reyes agree.

"We both knew that in order to stay competitive, given the fact the institution was decentralizing services, we needed some kind of technology where the images could be transferred to the radiologist for a virtual reading-PACS offered us that technology," Reyes says. "We knew what was out there, but we had to convince the rest of the institution that [making the transition] was not only going to provide better service, but also reduce costs for the institution."

Piece-by-piece, Dr. Swischuk and his team began rolling out changes in areas where the introduction of digital technology would produce the least amount of difficulty and the greatest positive impact. They began in the ER non-trauma and in an outlying outpatient clinic and used the success stories to generate positive PR, Dr. Swischuk says.

"The biggest culture shock came from the trauma doctors and surgeons" Reyes says. "They kept insisting they needed a hard copy, and we had to keep telling them that we're not in a hard copy business anymore."

Celina Bullock, RT(R), senior diagnostic technologist at UTMB, admitted that learning the nuances of digital radiography in the ER increased stress levels mildly during the early days of the project. Though none of the positioning techniques changed in going from a film system to a filmless system, adjusting to the computerized system took practice, and not having to handle film cassettes anymore took getting used to, she says.

In fact, for most of the technologists in the department, their first inclination was to revert to the conventional method when faced with obstacles, Reyes says.

"Once they learned the technology and accepted the fact that there was no going back, they too came around and decided, why fight it, let's learn it and let's try to improve upon it," he says.

Appointing key leaders

One of the most important steps to take during such a transformation process is to appoint leaders who'll cast the vision for a filmless future, Dr. Swischuk says. The visionary aspect entails maintaining a level of confidence when people complain that the old way is better, Reyes adds.

"You have to appoint a person who'll have the vision and the ability to get rid of impediments, which basically are individuals who are unwilling to change their modus operandi," Dr. Swischuk says. "You have to diplomatically tell them, 'We are getting to point B,' three times, 'and I'll work with you to make it as painless as possible, but understand we are getting to point B.'"

"Most of their fear is about not knowing how to do something new, they're comfortable with the old ways of doing things and so you just have to have good training," Reyes adds, noting that one of the most effective ways to win over reluctant learners is to identify key members within each department to become the "experts" who will then train the others.

The senior technologists and managers were often the point contacts in radiology and often the onsite trainers, Reyes says. While the vendors provided application specialists to work with the group collectively during shifts, the best resources often were the senior technologists who attended the short in-services offered by the hospital. And even after a few training sessions, education remained a continuous joint learning process.

"We had to hold their hands in the beginning, and once you get a few to champion the product, they in turn passed it on," Reyes says.

It takes patience and humor

Like anything else that's learned for the first time, without practice and repetition, it's easy to forget-that's especially true in a hospital setting if an application is not used routinely, Reyes cautioned. Most of the problems the supervisors were faced with from disgruntled employees were more often operator issues than mechanical issues.

"When you get up there you can forget the little things that you were supposed to do," he says.

"There are little things you need to do to compare today's films to last week's films, and a lot of [technologists] can forget to do a few short steps and get frustrated, and rather than asking the supervising technologist, they are ready to call the PACS hotline to help them pull up images and get somebody to fix the machine when there's nothing wrong with it," Bullock says.

The truth is that such scenarios are often the "norm" rather than the exception. Both Reyes and Bullock cautioned that a strong sense of patience and humor can come in handy for anyone placed in a leadership position during any major transition period. For example, most of the cases where images were reported lost in the system were primarily due to the fact that the images were not qued in the correct format.

"One time they reported that the screen was blank and that it wasn't working and so no one wanted to use it, but the screen was blank because the screensaver was black-that's the kind of stuff we had to deal with in the beginning," Reyes says, noting that other concerns raised by the technologists focused on film quality and uptime.

"But once they started looking at it, they felt the quality was good enough, the uptime had never really been an issue, and at the time we were also running dual systems, and so the backup would have been to return to conventional X-ray.

"Overall, radiology has embraced the technology and recognized its value, but it takes a lot of teamwork, a lot of understanding and a lot of patience to make it work-it's continuous because the technology keeps changing and we have to keep learning and keeping up with it," Reyes says.

Bullock, a technologist of nine years, agrees. Today, having mastered the technology, Bullock says neither she nor the other technologists in her department would return to conventional imaging, despite their initial objections and hesitations.

"The image quality is good, it's fast, the patient flow is much easier, it's easier on the patient I don't think there are many of us who would go back to conventional imaging after looking at the new updated equipment and technology now," she concludes.

Still to come (on October 30): Part 3 of this series looks at the transition into a paperless medical record system.

Jenny Ahn is an editorial assistant at ADVANCE. She can be reached at jahn@merion.com