X-rays controlled at a distance

The system of the control of quality on line, reduces the costs and the exposureof patients to radiation

The reduction of the exposure of the patients to x-rays and the decrease by 20% in the cost of the radiological films are some of the results obtained with the control of quality on line of the diagnosis via images, implanted by the company Unidade Radiologica Paulista (URP). The principal improvements are the reduction of the loss of quality of the image and the elimination of unnecessary doses of radiation caused by the machine’s poor regulation. Another advantage is the elimination of the operational technical visits to the clinic.

As yet at the pilot stage, this new process is a result of the project Development of a System of Remote Management for Programs of Guaranteed Quality in the Department of Diagnosis by Image , that the URP and the Technical Services of Medical-Hospital Appliances of the Institute of Electrotechnical and Energy of the University of São Paulo (IEE-USP) developed through the Program of Technological Innovation for Companies (PITE) of FAPESP.

The IEE has been working on the control of quality in the area of health since 1991, when it worked in conjunction with the University Hospital of USP. From that time onwards, it began to monitor the procedures of various companies: the technicians of IEE collect the data and afterwards analyze them in the laboratory. In the area of radiodiagnostics, the new system will make the work of checking the data easier. After concluding the pilot phase, the system will be available for all the clinics and hospitals who solicit the service.

Internet inspired
The URP, which has been working in this area for 40 years, approved of the program of IEE in 1993. Four years later, there emerged in the Institute the idea of creating a control which was even more efficient through the Internet which afterwards was expanded to cover the general public. Initially coordinated by Dr. Jean Albert Bodinaud, today the project is under the supervision of the physicist Dr. Paulo Roberto Costa, Chief of the Technical Section of Technological Development in Health of the IEE.

He coordinates, together with the physicist Dr. Tânia Furquim and the engineer Dr. Elias Roma Neto, a team of 12 people including engineers, physicists and technicians, who are responsible for the communication network. It is through this network that part of the data used in the evaluations of quality of a clinic is sent – various times per day over the Internet – to the central reception, storage and analysis center located in the IEE.

Once processed, the data passes for analysis to the physicists who emit the reports which are then placed at the disposition of the clients on the site of the IEE ( ). In any case where they show a serious problem, the person responsible for the clinic receives an alert via e-mail or by telephone. In this way it is possible to rapidly make the necessary corrections. As well as this, a group of professionals of the IEE remain available for clearing up any doubts and indicating procedures. “The most important thing is that those responsible for the control of quality in the companies look at the data which is divulged on the site.” affirmed Dr. Costa.

In real time
“The important step in this project is to make viable the identification and solution to a problem in real time.” revealed the coordinator. “The process of correction has become very quick.” he stated. He related that the index of rejection – inadequate examination of a correct diagnosis – registered today by the clinics varies between 15% and 20%. “It is a very high index and needs to be reduced.” emphasized Dr. Costa, who cited the ideal index at between 5% and 8%. He remembered that the control of quality in clinics of radiodiagnosis is obligatory in the State of São Paulo since 1994 and in the country since 1998.

Trustworthy examinations
To conclude the project there is the need to implant a system of the acquisition of the data for the remote control of the temperatures of the film processors and to automate the use of the pages on the Internet. Today, the IEE has only carried out the remote accompaniment of one of the three units of URP in the capital, São Paulo. During the first semester of 2001, the Institute will increase its service to the two other units of the company.

“Before we implanted the system, the time for the correction of a problem was up to three days. Today, this occurs in a few hours and on the same day.” said the radiologist Rubens Prado Schwartz, partner and owner of URP.For him, the efficiency permits the company to reduce the number of “false negative” examinations and “false positive” examinations which, if not redone, can create a lot of confusion. “A poorly regulated machine is responsible for the increase in the occurrence of these cases in a clinic.”

Dr. Schwartz revealed that the URP manages to remain within the band of rejections of 5%, recommended internationally. “The idea is to amplify the remote service for all the companies interested which already use the services of the IEE.” said Dr. Costa. As well as URP, 19 other Paulista radiodiagnostic clinics are clients of the IEE and they are still receiving visits from technicians: the system implanted by the IEE will be extended to them during the year 2001.

The financing by FAPESP was basically used for the importation of computer software and quality control equipment. Among the apparatus, a digital server which remains at the IEE, receives all the data and automatically processes it. In quality control, the outstanding piece of equipment is the sensitometer – a sensitometer determines and defines the characteristics of the radiological films, such as the velocity of the exposure and the contrast. The URP received as well a computer terminal, a modem with an exclusive telephone line, which receives and sends all the data of the examinations, a data collector with a bar code reader, and eight electronic precision thermometers.

As well as evaluating the working of the equipment, the work system shows the professional level of the professionals involved in the process. The software used in the program was developed by the IEE itself. At the URP, the workers responsible for the service rooms, feed the reception terminal the data after each battery of examinations. By way of an identity badge with a bar code, the person responsible for the source of the data is identified. The URP carries out close to 4,800 examinations per month at the Paulista unit, where 40 of the 100 workers are involved in the project.

The cost of implementation of the system at URP was R$6,000.00 and its use “gave a proportional reduction of 15% of the direct costs of our activity”, revealed Dr. Schwartz.

Broad band
The team from the IEE are thinking on further advances. The expansion of the service of broad band telecommunications in Brazil, for example, will permit an evaluation of the image by the network. “We are already studying ways to use this technology to broaden the range of our work.” affirmed Dr. Costa. For the coordinator, with the broad band it will be possible to cover practically all the problems which come up in the radiodiagnostic clinics. “The possibility of us having access to a copy of an examination or of a quality control test via the Internet is a great advantage by the use of the broad band.” The areas with the highest index of occurrences are already attended to by the project. “The access to the images would give even more amplitude to the control of quality.”

Dr. Costa remembered another motive for the creation of the service: there is a lack of qualified personnel in the sector for one to be able to carry out the service within the companies. “The number of students in the area of physics has been going down year by year in Brazil, since the difficulties encountered in the work market have finished up frightening away any interested youngsters.”

The researcher called attention to the fact that the remote quality control will permit a resolution of the problems of clinics which are distant from the large centers. He believes that for its range and for its reduction in costs, the project could be the solution to the problems of the radiodiagnostic clinics in the whole of the country, and concluded: “The project fits like a glove for countries under development such as Brazil.”

The project
The Development of a System of Remote Management for Quality Guaranteed Programs in the Department of Diagnosis by Images (nº 97/13103-8); Modality Partnership for Technological Innovation in Companies (PITE) Partner company – Unidade Radiologica Paulista (URP); Coordinator Dr. Paulo Roberto Costa – Institute of Eletrotechnology and Energy of USP; Investment R$ 20,852.00 and US$ 131,186.54 by FAPESP, R$ 39,500.00 and US$ 12,600.00 by URP