EyeNet Magazine

Practice Perfect: Information Technology

Should You Switch to Digital Imaging? Six Factors to Consider
By Patrick J. Saine, MED, CRA

Chicago, 1983. PAR Microsystems introduced the first commercial digital angiography system at the Academy’s Annual Meeting. They had lots of lookers, but few takers. Although the images were smooth, they weren’t quite perfect and the cost was sky high.

I thought, “Perhaps I should wait until the technology matures.” But when you are young, you want to make all of your own mistakes. I jumped in with both feet and learned the facts of digital imaging the hard way. If you are wondering whether or not to take the plunge, here are six factors that you should consider.

1. Digital imaging is here to stay. Although film will be available for the foreseeable future, a gander at the sales trends of consumer cameras indicates what is likely to happen in ophthalmic photography. According to figures obtained from the Photo Marketing Association, 2003 was the first year that more digital than film cameras were sold. In fact, the ratio of film to digital cameras purchased has reversed since the year 2000. That year, consumers purchased 4.5 million digital cameras and 19.7 million film cameras. Estimates for 2005 reveal a ratio of 20.5 million digital cameras to only 4.6 million film cameras sold. As digital imaging continues to capture film’s territory, film technology will be forced into a technological decline and a price increase.

Integrating your ophthalmic images into electronic medical records is another important issue to consider. The Bush administration is making electronic medical records a high priority and has set a 10-year goal for converting all medical records to a computerized format. Will your retinal photography be ready?

2. Digital imaging is a front-loaded expense. Your film-based ophthalmic photography consumable budget is probably dominated by the expense of film and processing. Digital imaging can reduce or eliminate this ever-increasing line item, but only with considerable up-front investment.

Nonmydriatic fundus cameras are useful for the practice that requires color fundus photographs to document retinal findings and follow glaucomatous disc changes, but refers angiography patients out. This system is also easy to use, with its infrared alignment procedure reducing the need for a skilled ophthalmic photographer. The disadvantage of these cameras is that they are only capable of color fundus images, which eliminates the possibility of angiography. Canon, Kowa, Nidek, Topcon and Zeiss all manufacture affordable digital nonmydriatic cameras. Prices begin at around $15,000.

Specialists in retina require a high-resolution digital angiography system. Expect the least expensive digital angiography unit to cost between $30,000 and $40,000, with the system approach required by a multicamera office to top the $100,000 range. 

When a practice evolves to a digital system, the physician can expect interaction with the patient to become more efficient, as angiography will be available for reading sooner. Your photography staff may gain little additional time in their day, however. Angiograms will still take the same amount of time to complete and previous darkroom time morphs into time required for the archiving, printing and the care of a digital system. If you have a darkroom, consider converting it into a photography-oriented computer workspace or an additional exam lane.

3. Digital imaging is a continuing expense. The promise of the computerized office is that we have access to continuously updated information. The curse of the computerized office is that we must continuously update computer hardware and software. Ophthalmic imaging is subject to the same technological changes as your clinic’s other computers. Hardware is often replaced in three- or four-year cycles. Digital imaging software upgrades annually or biannually, often coinciding with the Academy’s Annual Meeting. The good news is that you may not need to schedule a maintenance day for the company service rep to install new software. Most ophthalmic digital imaging companies install updates by dialing in to your computer from their tech support desk.

A required upgrade may not necessarily be due to changes made by your ophthalmic imaging vendor. The following is a true story. We had been archiving on CDs for about five years when, in 2003, we switched to DVDs in order to capture large color images. With our vendor’s help, we swapped out our CD burner for a 2X DVD recorder. This past week, our hospital’s computer supply vendor informed us that the 4x DVDs that we were successfully using in our 2X DVD drive were no longer available. They shipped us the replacement product: 8X DVDs. These did not work with our 2X DVD burner. Our solution? Swap the 2X burner with an 8X burner. A phone call to the digital imaging vendor’s help desk resulted in an overnight package. The 8X DVDs recorded well, but now our older 4X DVDs were not being recognized by the computer. Another call to the help desk resulted in updated software and resolution of the problem. This experience illustrates why service contracts are, in general, a good idea with digital angiography systems.

4. Digital imaging will help your staff become better photographers. An important advantage of digital photography is the instant feedback that it gives your photographer. Ophthalmic photography is a hands-on skill best learned through a combination of instruction and experience. Inexperienced photographers and those photographers who work in small practices may find it difficult to hone their skills due to lack of repetition. Since the retinal image is displayed immediately on the computer screen, the photographer will be able to evaluate the image and then make critical positioning and focus adjustments to obtain a sharp photograph.

5. Anterior segment digital imaging options are now available. Because retinal photography has been the bread and butter of ophthalmic photography, imaging companies have been lax in concentrating on the anterior segment. Recently introduced digital imaging options may change that. Two dedicated photo slit lamps were announced at last year’s Academy Annual Meeting. Topcon showed the 3.3 megapixel SL-D2 Digital Photo Slit Lamp. This simple unit captures slit-illuminated .jpg files directly to a compact flash card. Haag-Streit introduced the BX 900 featuring integrated flash and a dedicated camera body mount. In each instance, anterior segment images can be downloaded directly into an electronic medical record.

6. There are a variety of options to choose from. There are different digital imaging solutions for different types of practice. Large multispecialty clinics employing retina specialists pioneered digital angiography with dedicated, and expensive, high-resolution systems. Teaching institutions adopted digital solutions because information transferal technology (publications, presentations and the Web) requires digital solutions. The recent introduction of affordable digital SLRs allows smaller practices with certain older fundus cameras affordable upgrade options (see “Further Reading”). Note that home-grown systems that lack rigorous HIPAA-compliant databases may require tinkering. They are best left to inveterate do-it-yourselfers.

Meet the Expert: Mr. Saine writes frequently, lectures internationally and exhibits his photography in galleries and museums (www.pjsaine.com). His latest book is Ophthalmic Photography published by Butterworth-Heinemann. He is manager of ophthalmic photography at Dartmouth Hitchcock Medical Center, where he wrestles with the cutting edge of digital imaging technology. How can you recognize him? He is always the one with bleeding fingers.

Further Reading
“An Affordable Alternative to the High Cost of Digital Fundus Photography” describes a step-by-step process for adapting a digital SLR. To download it from the Ophthalmic Photographers’ Society Web site, go to www.opsweb.org and select “Publications.” (Scott, J. R. Journal of Ophthalmic Photography 2002;24(2):55).

“Ophthalmic Photography Using a Digital Camera” describes an inexpensive digital solution for slit-lamp images, using an adapter to connect a Nikon 990 to slit-lamp oculars. Of course, that specific model of digital snapshot camera is obsolete. But the authors explain these main points: that you can focus a snapshot camera on infinity, align it to the ocular, and use the camera’s LCD to monitor the image. The article is available online at aios.org/ijo. (Fogla R. and S. K. Rao. Indian Journal of Ophthalmology 2003;51(3):269–272)

“Make the Most of Digital Cameras,” which describes how an inexpensive digital camera can be used to take external and slit-lamp photographs, was published in the April 2005 issue of EyeNet Magazine (Pearls). To read it online, go to www.eyenetmagazine.org/archives.

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