Experience with computer radiography and radiology in rural Zambia

Introduction

Is computer radiography/radiology feasible in a remote African setting? This is a report on our experience with computer radiography (CR) in Chitokoloki Mission Hospital, situated on the banks of the Zambezi river in North Western Province, Zambia.

Method

In August 2011, a CR system, comprising a desktop digitiser, computer, software, cassettes and a UPS (uninterrupted power supply) was installed, replacing manual wet processing of film in a darkroom. The X-ray equipment that was already being used did not require alteration. Cassettes with a digital plate were used instead of cassettes containing screen/film. The equipment package was sourced overseas as a suitable local supplier was not available at the time.

Installation of this equipment was delayed until a reliable electricity supply was available, as power from a diesel generator for a few hours per day was not constant and spikes in power during start-up and shutdown could ruin the computer equipment. The hospital had installed solar panels with a bank of batteries and inverters to supply 24-h power before CR was contemplated.

The initial setup costs were approximately US$30,000, funded through Mission-affiliated donations.

Results

Installation and setup was not easy and there were unique problems encountered. These included:

Lack of personnel available to install and service the equipment owing to the equipment having to be sourced overseas.

The immediate benefits of installing CR were the absence of need for a darkroom, film or chemicals. Furthermore, the digital image is available for viewing within 1 min, compared to a wet film which requires 15 min with wet processing. All exposures were half (milliamp-seconds) those used for screen/film combinations. This meant that each exposure was half the radiation dose to the patient, using the digital system. The need for repeat examinations for wrong exposures was virtually eliminated as the digital image allows greater latitude as well as windowing of the image for correct presentation. The connection of the CR computer to the Internet not only allowed software service to be performed, but a Web Client in the software allowed access to the database from anywhere in the world online. This allowed teleradiology to be possible and actually commenced working from August 2013. Most studies performed since then have been reported remotely by an Australian radiologist, registered in Zambia, interested in providing this service without remuneration. The time difference between Zambia and Australia means that the images produced during the day in Zambia (one shift – 07:00 to 13:00) are reported during the evening in Australia (16:00 to 22:00).

Another benefit was the ability to view examinations in the outpatient clinic during patient consultations, without having to go to the Imaging Department computer. This, however, required a separate computer and wired or wireless access for the Outpatient Department. Lost, displaced or misfiled film bags have become a thing of the past. A patient’s images, including prior studies, could be accessed from the database by searching with any of the following: hospital number; patient’s name; study date; or date of birth.

With digital imaging, saving studies, retrieval of prior examinations and archiving of teaching cases have all become much easier. Teaching file cases are of higher quality as a jpeg file is easily saved from the computer, compared to a digital photograph of the film on a lightbox. If a patient has to be referred to another hospital, their imaging can be sent on a CD (Dicom data) or USB memory stick (jpeg files) which are readable by any computer.

The long-term change in the number of patients/examinations per month with other patient hospital data is presented in Tables 1 and 2.

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Table 1.

Hospital data from before and after CR installation.

	1976	2008	2009	2010	2011 CR	2012	2013	Telerad	2014	2015
X-ray (exams/month)	49.7	54.1	79.6	90.6	97.7	90.5	137.8		150.9	160
Change (%)		8.9	47.1	13.3	7.8	–7.4	52.3		9.5	6
Surgery
Major	377	719	1210	839	1191	907	612		684	652
Minor	307	321	387	461	345	304	400		647	769
Total	684	1040	1597	1300	1536	1211	1012		1331	1421
Change (%)		52	53.6	–18.6	18.2	–21.2	–16.4		31.5	6.8
Admissions	2818	2207	2654	1900	2000	1451	1707		1636	1999
Change (%)		–21.7	20.2	–28.4	5.3	–27.5	17.6		–4.2	22.2
OPD attendance		16782	17685	16537	17248	9832	12966		8496	9103
Change (%)			5.4	–6.5	4.3	–43	31.9		–34.5	7.1
New TB cases		74	65	87	58	71	59		78	74
Change (%)			–12.1	33.8	–33.3	22.4	–16.9		32.2	–5.1

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Table 2.

Percentage of X-ray examinations to total patients treated.

Years	Total patients (outpatients and inpatients)	Total X-ray examinations	X-ray examinations (%)
2008–2010	57,765	2692	4.7
2011–2012	30,531	2258	7.4
2013–2015	35,907	5384	15.0

From Tables 1 and 2, the average yearly increase in radiographic examinations since the introduction of CR is 15.3%. Prior to this, in the 32 years between 1976 and 2008, the number of examinations was fairly stable. The increase in X-ray examinations during that time was less than 10%, an average of 0.28% per year.

The percentage of X-ray examinations to patients treated, has risen from 4.7% to 15%, when the three years prior to CR introduction are compared to the three years after CR and teleradiology introduction.

Discussion

The main improvement with the introduction of CR into a remote setting would normally be a decrease in radiation exposure and less repeat examinations. This comes with improved quality of images. However, an increase in the number of repeat studies in some patients, when clinically necessary, has been found, particularly in patients with fractures, post reduction and progress imaging, and in tuberculosis patients where clinical circumstances had changed.

The facility for remote reporting (teleradiology) has been a major bonus, as there are currently no radiologists in rural Zambia. Local staff no longer have to interpret the images themselves, as was done previously. This has resulted in improved patient care with timely accurate reports of the examinations requested.

The need for a backup radiologist has not arisen to date as the images are accessible from wherever an Internet connection is available. However, there is also no shortage of Australian colleagues who have expressed a desire to do something similar in a Third World setting. So, if it is necessary, help with reporting would be readily available.

Increased workload has not necessitated any increase in staff as CR is much more time-efficient than manual wet processing. Moreover, with the increased use of radiography, there has been no increase in the cost to the patient as all diagnosis and treatment is free. When there is a charge for radiology services, this would obviously impact the numbers of examinations and availability, with poorer patients being disadvantaged.

The hospital cost, apart from initial costs, include the service contract which is somewhat offset by the savings on film, processing chemicals, film bags and storage. If payment is necessary for the reporting of examinations, this would be considerable, as it is the major cost, apart from equipment, in western societies.

Although the experience of CR system operating in a remote Third World setting has been successful, and ongoing, there are no plans at present to set up similar schemes elsewhere.