CLARITY Orthopedics is a specialty that greatly benefits from high-definition cameras and monitors.

"Who needs to dictate?" asked one of the orthopedic surgeons at TMC Orthopaedic Outpatient Surgery Center in Tucson, Ariz., upon seeing HD pictures for the first time. "These pictures are worth a thousand words!" Yes, the differences between HD and the older versions of endoscopic pictures are dramatic. But let's put aside HD's gee-whiz appeal for a moment and consider how to make a smart purchasing decision. To be an educated consumer of orthopedic imaging, you'll need to look beyond the beauty of what your eyes can behold.

IMAGE CAPTURE Today's orthopedic imaging equipment lets you create DVDs of surgery.

The HD shopping list

It's a lengthy shopping list for high-def endoscopic equipment. For arthroscopic surgery, you need scopes and camera heads, a camera box, light cords and a light source, a monitor and printer, and an image router to send images and enter patient data, says Gabrielle White, RN, CASC, executive director of perioperative services and networks at the Hoag Orthopedic Institute in Irvine, Calif. And don't forget a cart to place the equipment on and wheel it around from one side of the patient to the other or from one OR to another, says Ms. White.

It would be nice to do a simple side-by-side comparison of the video and picture quality for each of the top vendors' offerings, but little separates today's HD cameras and monitors when it comes to image quality. One is as superb as the next, those we talked to say. "Your surgeons and staff wouldn't notice a distinguishable difference between each vendor, at least not an obvious choice that would impact your decision," says Brooke A. Day, administrator of the Hastings Surgical Center in West Hastings, Neb. So, where do you look?

1 Image capture, storage and transfer. The benefits of operating in HD are obvious: Surgeons and staff can see what the camera head sees in brilliant quality. But don't forget about the post-op utility of capturing high-resolution photos and high-definition videos of surgery. This is surgical marketing and education at its best.

Not many years ago, surgeons could only hand their patients printouts of grainy arthroscopy images. Now, surgeons can digitally share crystal-clear photos and DVDs with patients and transfer them to their mobile devices. "You need to find out how to store the images taken in the OR so that they can be displayed on the surgeon's iPad or similar device and shared with patients and their families," says Stuart Katz, MBA, FACHE, director of the TMC Orthopaedic Outpatient Surgery Center. "Find out how the system you're considering can send captured images to surgeons' offices so they can have them for post-op visits with the patient."

How will you capture images and videos? Ideally, they should be integrated automatically into your EMR system directly from your digital capture device, says Charleston, S.C., orthopedic surgeon C. David Geier Jr., MD. "It's also important to determine the size of the file and the type of file you save the images as for future use," says Ms. Day. Typically, she says, you should save high-resolution images as JPEGs.

Ms. White says audio-visual capabilities for surgical conferencing are nice to have, but can be costly. "In my experience, having digital audio-visual for surgical conferencing in our ASC was a waste of money," she says. "At the time, it sounded good and the surgeons agreed we would need it one day. Six years later, not so." If you're heavy on teaching remotely, Ms. White says it might be worth considering or at least planning for: "Have the vendor place the conduits in the ceilings or walls for future wiring if you determine a need," she says.

IMAGE ISN'T EVERYTHING Surgeons love to operate in HD, but you have to look beyond the crisp, clear images in order to make an informed purchasing decision.

2 Image quality. The image may be only as good as the light provided, says Marlene Bruns-wick, RN, MSN, CNOR, director of perioperative services at Blanchard Valley Hospital in Toledo, Ohio. The light source and light cables must provide great light output, she says. Also look for a light source that's safe and environmentally friendly. "Lights can be hot and dangerous," says Mr. Brunswick. "Look for one with cooler light emission during procedures and with an automatic standby mode when detached from the scope. Reducing injury to staff and patient and limiting fire hazard risks are important." It's a nice feature if the surgeon can control the light output settings from the camera head, says Ms. Brunswick. Newer LED light sources are more expensive initially, but last much longer than traditional Xenon bulbs, says Dr. Geier.

3 Versatility. A high-definition system that you can only use for orthopedics might not be your best option if you're a multi-specialty center and your case mix isn't primarily orthopedics, says Ms. Day. Find out if you can use your HD system for cases other than orthopedics and sports medicine. "Many of these systems can be used for ENT and other surgeries performed with a scope," says Dr. Geier. "If you're making a minimum $70,000 investment for each operating room, it benefits the center to plan for the long term and other potential uses in the future," says Ms. Day.

4 Service. "There's no use getting the lowest deal possible if you end up suffering from poor service and support," says Ms. White. "Does the vendor offer great service reps that will be there for your surgeons and staff, offer in-services and help troubleshoot the equipment?" Like any capital equipment purchase, you want "a reliable rep who'll check on problems quickly and troubleshoot problems even before they happen," says Dr. Geier.

"Vendor reps must be available for your support if you have issues with the equipment," says Ms. Day. "A loss of equipment could very well result in a loss of revenue, especially if you don't have the luxury of having a system to use for backup."

5 Sterilization. Some lenses, camera heads and light cords are autoclavable, while others need newer but more expensive systems to sterilize them. If you buy non-autoclavable items, plan to purchase additional equipment or count on more turnover time between cases, says Ms. Day. Autoclavable equipment can be sterilized within approximately 10 to 15 minutes, depending on the manufacturers' guidelines. Non-autoclavable equipment sterilization times, meanwhile, can be 20 minutes or longer. "You must factor in the costs to sterilize the camera heads as well as the wear and tear of multiple cleanings," says Dr. Geier.

6 Maintenance costs. "Just because an arthroscopy system is cheaper than another, the real costs might not be," says Dr. Geier. "Find out the labor costs per hour and factor that into the cost to buy the equipment." Adds Mr. Katz: "The price you pay to acquire the products is not half as important as the cost of the extended warranty and service provided in the event the system fails to work properly after installation."

VIEW FROM AFAR

An HD Camcorder in the OR

HOME MOVIES Attach a high-def camcorder to a light stand and position it over the surgical field.

We attach a high-def camcorder (SONY HXR-MC1) to a gooseneck boom arm hung off a heavy-duty tripod stand, which we counterweight with a leaded X-ray vest or sandbag, and position it over the surgeon's shoulder to give surgical team members clear views of the action. That way they can track case progressions and anticipate surgeons' needs without crowding the bedside space. The camera's cable is approximately 9 feet long, letting staff members stand safe distances from the surgical field while operating the camera remotely. An LCD monitor on a separate control device lets surgeons preview the video. The cost: about $2,000 for the camera, recording media cards, heavy duty stand and gooseneck boom arm.

— Timothy R. Palaszewski

Mr. Palaszewski ([email protected]) is a medical photographer and graphic artist at UB Orthopaedics & Sports Medicine in Amherst, N.Y.

7 Efficiency. Your clinical staff will appreciate the ability to enter patients' demographic information into the video system before the start of the day's cases. "This will decrease the turnover time between cases," says Ms. Day. "Although it's not extremely time consuming, when you are operating at the highest efficiency possible, every second counts." The benefits of enhanced camera options may include wireless transmission capabilities, programmable buttons on the camera head, HD and HDTV outputs, flat-panel monitor images, and touchscreen LCD interfaces for navigation, says Ms. Brunswick. Surgeons like to be able to control focus and white balance from the camera head, says Mr. Katz.

8 Involve your surgeons. Make sure you get what you need; you can always add more later. "Have at least 1 champion surgeon who is knowledgeable in the technology and procedures and who understands the financial commitment and impact on the facility," says Ms. White. "MDs are an asset on your negotiating team, get them involved. Research the vendors and what they have to offer and decide on no more than 3 to trial." Ask each vendor for at least a month-long trial, says Ms. White. "This allows time for everyone to be best acquainted with the vendor, the equipment and figure out any deficiencies in equipment, support or workflow."