Medical Progress

One of the ‘improvements’ in medicine the last few years has been the shift away from xrays on film and to digital radiography. It has a lot of things going for it, mostly relating to cost. Don’t let anyone kid you, it’s all about the money.

This has led to the execrable state of todays’ affairs, when patients are transferred with CD’s instead of films, which aren’t made to be particularly useful. For instance, here’s the disclaimer that pops up when my latest transfer arrived: (click for larger)

AGFA viewer

Now, that’s handy: “NOTICE: This CD viewer has been provided to you for reference purposes only and this viewer application should not be used for diagnostic purposes.

What? This is the embedded viewer to view the CT images that accompanied the patient, you can’t see the images without the embedded viewer, and it’s “not for diagnostic purposes”? In the good old days (two years ago) patients came with real films, and they were useful for, and used for, diagnostic purposes.

Another victory for the cost cutters and the scourge of lawyers. Thanks for the help.


  1. Do not X-ray Happy Fun Ball!

  2. While working on award in the sunny uk, I came across two junior Drs text messageing there consultant an xray, while he was at home (not terrably legal). They were not sure what the xray showed. The consultant arrived 20mins later looking paniced. I guess the xray showed somthing intresting. So they do work. In my trust we have both, hard coppies and digital. Tho the manager types want to get rid of hard coppies.

  3. Anonymous says:

    In a couple of hours my wife and I are flying into Honolulu from an outer island to consult with a surgeon with CT hard copies in hand. I had no trouble getting films even over the weekend.

  4. On your coat: This Emergency Medicine Physician is for informational purposes only, not to be used for diagnostic, prognostic, or therapeutic purposes.

    GD, I didn’t make it through all the comments on your last post because so many were so negative. (It appeared that some of the posters had a long-standing and contentious relationship.) Yesterday I had a straightforward nursemaid’s elbow which I taught one of our med students to reduce, which she did in triage to the amazement of the patient’s family. I realized there are still some things about this job that I love. You just have to look harder and harder for these moments. I hope Jeremy is not too discouraged.

  5. There’s no reason at all these images can’t be stored as high resolution JPEG files, easily read by any photo viewing software.

  6. GD,

    I concur with your cynicism (as is required of all practicing EM docs), but I think in this case the obstacle may be technical. Try this experiment with your Dig Rad system, if it will let you. Save an image to disc; it will probably automatically save itself as a JPG. Then blow that up to max mag, and compare that to the same image’s max mag in your native viewer. The difference is probably astonishing. The point is that there is a lot more to those pretty pictures that we love so much than is readily apparent. So if they just put them on the disc as jpgs, there would be a serious loss of data quality. (even moreso with CTs than with plain films.)

    I don’t know about the viewer you used on the CD — it may have some loss of data quality compared to the originals which requires the disclaimer, or it may be a lawerly CYA thing — I suspect the latter, as the images I have had patients come in with on CDs were really good.


  7. Dang. I was going to blog about this!

    I have the same gripes, especially the “not to be used for diagnostic pruposes”.
    Not acceptable for me as a neurologist. My other bugaboo is viewing in the hospital.
    At the main hospital I work in, we can all view images throughout the hospital.
    But then you go down to where the radiologists work, and they have HUGE, DOUBLE-MONITOR setups, with VERY high resolution. I asked one of the radiologists if maybe they could make one of these available for us nonradiologists; his immediate response was “Do you know how expensive these are?”, as if his group paid for them.

    This is all part of the neurodoc rant that what has happened is there has developed an attitude that the radiologists are the only ones trained to read Xrays, the rest of us just want the report. Grrrrrr. I continue to read CT and MRI scans because I have to make sure I pick up all their mistakes.

    The native image format for radiology is DICOM. What happens on many of these CDROMs is that this is converted to JPGs, sometimes with VERY bad settings. I can at least get CDROMs at this above-mentioned hospital which have the DICOM images on them, and with a program called ImageMagick, it is possible to view these separate from the canned software.

  8. Shadowfax, that’s the point the copies on CD are not useful for diagnostic purposes — so why get them? The whole POINT of CT scans are for DIAGNOSES! It would be like getting a prescription drug that states “Not for treatment of disease.”

  9. Sorry, I wasn’t too clear — I answered two questions at once. BadShift asked “Why not use JPGs?” The reason not to use jpgs is the loss of data. But it wasn’t clear from GD whether he was actually getting good quality images with a meaningless disclaimer or whether he was getting crummy images with a real warning. The CDs we have use high quality images (the DICOM name sounds familiar — thanks, Greg P), and from my experience could be used for diagnostic work. Though ours don’t come with a disclaimer.

  10. I didn’t want to confuse the original rant with the subsequent one, but I couldn’t read the images! I’m fairly computer literate, yet I couldn’t get past the first 4 CT slices.

    Oh, I could change the levels, and change the slice orientation, but not look at the subsequent images.

    So, their stupid disclaimer is true, they’re not for diagnostic use, they aren’t useful at all.

    I do like the disclaimer idea for the lab coat and the prescriptions, though. Bring a little more absurdity into our bizarro practice.

  11. Don’t worry, Bad Shift, I’m in the mix for the long haul.

    As for x-ray viewers…

    The neurosurgeons at my hospital have a view two-panel hi-res viewers. Some of the neuro clinics have them as well. They are scattered throughout the hospital for general use too. They are, beautiful.

  12. Anonymous says:

    removed by GruntDoc. I hate spammers.

  13. HGH — broke we may be, but I don’t think that anybody is ready to start rationing just yet. (not counting the 47 milllion uninsured who get no health care, but that’s not exactly rationing, is it?) It is true that we spend more for healthcare, and get less, than any other developed nation. I am not optimistic that anyone will recognize or address the underlying causes. But the problem is not the digital radiology, nor CT scans, nor doctors’ salaries. The problem is the ‘market-driven’ insurance model we all labor under. 25% of all healthcare dollars are consumed by administrative costs. Commercial payors waste dollars on advertising, big bonuses for CEOs, dividends for shareholders, while going to huge effort to deny payment for claims made. The payors do not focus on preventative care because it is a money-loser for them.

    There are other stressors — the aging of america, expensive drugs and new procedures, etc. Sure, it’s multifactorial. But until america wakes up and demands some sort of universal-coverage, streamlined single payor system, we’re going to continue to go deeper into debt. Maybe it will take worse healthcare, as you say, for americans to wake up and smell the melena. But heck, we’ve already got worse healthcare — come to my ED on a monday night and see the patients in the hallways if you need proof.

  14. Shadowfax, I had to delete the comment you were replying to, as it was just a sham vehicle for a medical product spammer. Ironically, the guy railing abou the system being broke was hawking a very expensive therapy for use WELL OUTSIDE the standard medical uses.

    I like your argument, though.

  15. Greg P states:

    “This is all part of the neurodoc rant that what has happened is there has developed an attitude that the radiologists are the only ones trained to read Xrays, the rest of us just want the report. Grrrrrr. I continue to read CT and MRI scans because I have to make sure I pick up all their mistakes.”

    Well, I sure hope you bring up all of those mistakes to the Medical Staff, and get responses from those self-righteous radiologists! In my experience, the only reason neurologists want to read CTs and MRIs is to get a piece of the pie! But, I am sure, you have no ulterior motives.

  16. I cannot speak to my neurologist friend’s motives, but I have to be able to read CT scans on my trauma patients at night and make real-time treatment decisions. I cannot count the number of imaging studies I have had to repeat because the images could not be retrieved from the discs or when obtained, were worthless.

  17. I have a few comments about this as an engineer that often works with computers and digital pictures. JPEG is a lossy compression format – that is, it is designed to save space by losing some fine details that no one notices in pictures for ordinary purposes. Radiography obviously isn’t an ordinary purpose. Read the specs before you unthinkingly use the standard from another field!

    Some software allows you to control the amount of lossiness when saving an original image to JPEG. That might solve the problem and allow the use of standard JPEG viewing software, provided it can zoom in far enough. I’m not sure if that or anything else allows enough compression to get a set of several full-quality XRays onto one CD.

    You might also be losing image details just from digitizing, even if the pictures are stored as full bitmaps. Digitizing breaks the image up into little blocks and assigns a single intensity number to each block. In some ways this is more accurate than the analog processes of film exposure and development, but it may obscure fine lines and subtle intensity differences that are recorded on film. You avoid that by overkill – by having pixels as small as one grain of silver on film, and by using enough bits per pixel to record intensity differences down to the scale of random variations in the photographic process. However, this overkill not only makes the camera or x-ray sensor much more expensive, but it greatly increases the file size.

    I would feel a whole lot better the next time I go in for a radiograph if this discussion had been about images burned into a writeable DVD rather than CD-ROM…

  18. Being a neurologic “greybeard” I have read/analyzed my own CT since 1978 and MRI’s from 1983 (when they were callere NMR). I am getting my outpatient studies on CD as Dicom and I am using a freeware program called OsiriX (sorry Mac only). The software is actually more potent and flexible than some of the excuses for workstations I have seen radiologists use. I am happy to get rid of films, which often are of poor quality. The ability to directly compare 2 views (sagittal/axial or T1/T2 etc) has been invaluable. I understand the radiologists reluctance given that they are not clinicians in the strict sense of the term. Also I use the display to explain and review the findings with my patients. The clinical and LEGAL benefits from directly sharing with patients alone is a major benefit.

    The radiologists I use have been trained to give me the full Dicom file and not bother with jpg’s.



  19. neurosurgeon says:

    Last time I checked any doctor could bill (and get paid) for an Xray report if the following criteria were met:
    1. You submit a written report
    2. Your interpretation is significantly different from the radiologist’s existing written report
    3. If you are just reading/interpreting the Xray and your facility has NOT performed it (used its machine or tech) then you have to add modifier 26 (professional component only).
    Remember, CPT says that all the codes may be used by any doctor; not only do neurosurgeons, plastic surgeons, orthopods and general surgeons do carpal tunnels, but we can all read an Xray too.

    I discovered this when I started doing lumbar discectomies and anterior cervical procedures in an ambulatory surgicenter which did not offer on-site radiology services and did not have digital Xray capability. I was reading my intraoperative films and felt I should get paid for it; the description of the operation does not include the reading of intra-operative films. The facility kept a copy of the report, I kept a copy in the patient’s office chart, and I kept the film at the office too. I always got paid. Of course there was no existing radiologist’s report, but once I knew HOW to bill, I then decided to issue supplementary reports on those Xrays that came in to my office (usually when a new patient came for a consult) when my interpretation was significantly different. I took care to state in my Consult that my opinion was different from that of the original reading radiologist as well as what my opinion was. I didn’t say anything in my Consult about issuing a separate Xray report; I just issued it separately and billed it with -26.
    Always got paid.

  20. neurosurgeon,
    You probably can, if you don’t work exclusively in a hospital where the radiology department has the ‘exclusive billing’ clause for radiologic services. Right now they don’t care if we use our US machine in the ED, but they do care if we bill (even though the ED uses different codes) because it interferes with their exclusivity.

    As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn’t important so I could do it when it’s convenient for me.

  21. “As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn’t important so I could do it when it’s convenient for me”

    GD–Are you sure that it is a day or more until your plain films are over-read? More likely they are read much sooner than that, but you don’t get a report as soon as you would like due to various non-radiology issues–transcription, distribution, etc. Of course you will not be completely satisfied until you have an on-site radiologist babysitting you 24/7. I am sure there are mechanisms at your hospital to get something read very quickly, but you would rather complain. I have an idea: Complain to administration about the situation! Get a new radiology group with better babysitters!

  22. Babysitting? How about working for the money that’s paid to them? We’ve asked, several times, that this be included in their contract when renegotiated. It never seems to make it it.

    Radiologists like to argue it both ways: their input is extraordinarily important to the process, and it doesn’t need to be done while the actual care is going on. Phoo.

  23. Last I heard, ER docs are supposed to be able to read plain films from the ER. Are you worried? Also, wasn’t there talk awhile back about ER docs getting paid instead of radiologists for Medicare patients seen in the ER? Get on this bandwagon. Good idea–>lobby for reimbursement for ER docs only for all ER films if they see them first! Bring that up to the insurance companies! Accept the liability! Make more money! Also, do you think that you can find many radiologists who are going to stay up all night long to look at an endless number of “emergency” exams. I really don’t think that you have any problems getting radiologist input for exams that really matter (CTs US etc) And, if you have any problems with those difficult plain films, just CT it as usual–distribute the liability to the radiologist. Of course, you probably have complaints about how fast you will get that CT report as well. Don’t forget: radiologists are not there for the ER only. There are also hospital inpatients, procedures, outpatients, etc. Get a grip. It is not going to change. Suck it up. Once we have socialized (sp?) medicine, it will not matter.

  24. Frankly, if there’s any ‘sucking it up’ to be done, I’d expect it be from the people who get paid to read the films.

    #1 payout reason for EM docs? Missed fractures. (Not the biggest ticket, but the most common reason for settlement).

    Funny, the exams that ‘really matter’ are the ones that my patient needs, not the ones you enjoy reading or that come out of fancy machines.

    I have to guess you’re handling the radiology contract negotiations for your group.

  25. Cross-posted at Movin’ Meat

    GruntDoc ranted:

    [Our] hospital where the radiology department has the ‘exclusive billing’ clause for radiologic services. Right now they don’t care if we use our US machine in the ED, but they do care if we bill (even though the ED uses different codes) because it interferes with their exclusivity.

    As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn’t important so I could do it when it’s convenient for me.

    I won’t claim to be the most experienced voice in this field, but from what experience I have, this seems to be a common problem: radiologist groups who will or can not deliver real-time interpretation of plain films, due to high workload and staffing difficulty. Most do give readings of CTs and Ultrasounds, and deliver over-reads of plain x-rays, usually within 24 hours. But from our side of the fence, this creates huge operational problems in the ED — the massive amount of time spent reconciling the discrepancies between the ED docs’ original reads and the final radiologist’s report, the potential harm to patients, the pissed-off patients who had to be notified that an “error” had been made, the increased liability from even trivial discrepancies, etc.

    As you might expect, it can prove difficult to convince the radiologists to give real-time reads on plain films, especially at night, since they are getting paid either way and it is hard to find docs to work between the hours of 11PM and 7AM. Hospital administration, though sympathetic, may claim they have have little power to compel the radiologists to come around. So many times the ED physicians suggest that since they are, for whatever reason, obligated to deliver care solely on the basis of their own interpretation of the X-rays, that they have provided the service to the patient, assumed the risk, and deserve the compensation.

    Beware that when you raise this point, you are igniting a turf war. It’s one you can win, though, if you have the will and an adequate political base of support within the hospital. It is important to have defined your goals in advance: some ED groups see this as an important business opportunity and a significant source of revenue worth fighting for. Our philosophy, when we addressed this a few years back, was that we did not want to be reading the X-rays, that we wanted contemporaneous interpretations. So we play the role of “patient advocates,” arguing that the best care is a real-time reading of all radiographs by a radiologist. This is a nice tactic to take because it clearly puts you in the white hat, and I think is probably where most ED groups find themselves trending. But it is backed by a real threat that we could bill for the interpretations ourselves if this service is unavailable.

    This threat has teeth because, on a routine basis, most payors, most notably Medicare, will only pay once for an X-ray interpretation. If only one bill is received, they pay it without question. If more than one provider attempts to bill for an ER study, the CMS policy is that the provider who performed the interpretation at the time care was delivered to the beneficiary is the individual who will be compensated. Though I have not heard of any OIG investigations on this matter, the implication is very clear that if the radiologists also attempt to submit a bill for payment, that practice would be at the least noncompliant and at the worst, fraudulent.

    Similarly, I might suggest to GruntDoc’s hospital administrator that the radiology group’s “exclusive” contract for interpretive services is also noncompliant and possibly illegal since it would seem to prevent other physicians from billing for services legitimately rendered to beneficiaries.

    The other major objection to ED physicians performing the primary reads of ED X-rays is QA, which is required under Medicare part A. The response to this is that it is simply not our problem — that is a hospital function. If the hospital has to pay the staff radiologists for QA over-reads on X-rays that the ED physicians have already billed out, the hospital may suddenly find that it has a dog in this fight and the pressure on the radiologists to provide timely interpretations may suddenly increase.

    Either way, I view this as a win-win for the ED and well worth the effort to fight it out. Either you have the option of billing your own X-rays and the (modest) revenue that would accompany it, or you get real-time radiology reports on all your X-rays and the higher level of quality and security that comes with that service.

    And by the way, every word I have written on this subject can be as easily applied to ECGs as well as to X-rays, except that real-time interpretations from cardiologists are much less useful or likely to occur.