• buy 
• sell $
• about
• My DOTmed 

This report originally appeared in the November 2009 issue of DOTmed Business News

Although radiographic and fluoroscopic equipment are linked because they both begin with an X-ray source to initiate the imaging process, the Rad and R/F rooms containing the equipment do have their differences.

While each does provide radiographic and chest imaging, the R/F room can put the image up on a monitor to offer live imaging. Both modalities usually occupy the same location in a hospital and offer a similar room layout, but the R/F room, as the name suggests, is set up for radiographic and fluoroscopy procedures.




"R/F systems are more complex because you are dealing with much larger (X-ray) doses and you need more control in terms of management and you need more preset configurations," said Scott Burkhart, Vice President, General X-ray for Philips Healthcare. "The difference is really in the imaging chain and how you deliver X-ray dose and that's really in the design of the product itself."

An R/F room can also be set up as conventional, where the physician stands right besides the patient, or remote control systems, where they sit in a control room behind a leaded glass window.

"In the U.S. market, it's probably about 80 percent conventional because that's the way physicians were trained," said Tom Treusdell, Director of Product Marketing for X-ray & Fluoroscopy at Siemens Healthcare. In the rest of the world, Treusdell said, it's nearly the opposite, with 80 percent of those countries utilizing remote options. This is because by the time these rooms were constructed, there were significant findings of the hazards of extensive exposure to X-ray radiation, so those professionals opted to work outside of the radiation field.

Business Is Down

Industry experts estimate that the X-ray business has dropped more than 30 percent in the past year and the radiographic and fluoroscopic equipment manufacturers are feeling the effects.

Currently, Siemens, Philips and GE comprise a large percentage of the market on new equipment, with other companies such as Toshiba, Cannon and Shimadzu having made inroads in recent years.

"Hospitals are looking at what funds they have and they are a lot more cost-conscious. The economy has hit everybody along with hospitals so the market itself has dropped dramatically," said Treusdell. "A lot of people are waiting to see if they can stretch out their current system a little longer. Not everyone can wait. Maybe the system is on its way out or already to a point where they can't use it anymore."

With the products the OEMs are bringing to market, it seems they have subscribed to the notion that they have to do more and be more efficient with less.

"Clearly, the economy is the number one factor," said Burkhart. With the current uneasiness and high unemployment rate, less people are opting to undergo elective procedures, meaning there's less income flowing into hospitals and clinics. "Hospitals are becoming very conservative on releasing capital dollars to spend and I think they are making do longer with systems they have," said Burkhart.

The OEMs aren't the only ones feeling the crunch of the economy. Refurbishers, used dealers, servicers, dealers and brokers are all struggling when it comes to the Rad and R/F systems.

"DRA cuts are forcing more stringent things to be done by healthcare providers. Plus the tight credit markets are not helping small and mid-size diagnostic imaging facilities in getting newer equipment," said Leon Gugel, President of Long Island City-based Metropolis International, a stocking dealer that sells pre-owned and refurbished Rad systems. "That is great for the used market. However, the actual used systems usually come from trade-ins. And with fewer new systems going in, there are less units appearing on trade."

The Right Equipment

When it comes to Rad and R/F equipment choices, it can run the gamut from portable X-ray machines to heavy-duty remote R/F rooms.

According to David J. Voegtlin, owner of Texas-based Diagnostic Excellence, there are many factors to consider in the selection of a radiographic system, including understanding what procedures are to be performed and the range of patient size.

"This will help determine the KW rating of the generator and whether a standard room or a C-arm configuration like Canons URS is desirable," he says. "Size of the patient must be taken into consideration, as the capacity range of tables is from 300 to 700 lbs."

It's also important to know if the patients are ambulatory or not, which will determine whether an elevating or standard non-elevating table is desirable.

Finally, Voegtlin said, you have to know what type of receptor will be used.

"CR eliminates the need for film and a film processor, but does not dramatically increase patient throughput and efficiency," he said. "DR on the other hand, increases throughput and decreases fulltime employee hours per procedure and should be the receptor of choice for facilities that want to decrease patient wait time and increase employee efficiency."

Digital Radiology vs. Computed Radiology

The advent of DR technology has decreased the time that it takes for images to be taken and sent to the radiologist. This in turn, decreases patient wait times and increases the efficiency of the staff.

"We recently upgraded an existing Siemens room in the orthopedic department of a large hospital in Fort Worth, Texas with a Canon DR panel. X-ray used to be a bottleneck for patients, as they would wait for hours to get their X-rays taken," said Voegtlin. "The switch to DR from CR has minimized the wait time and now the patients are in and out of the department in one third the time it had previously taken."

This facility was so impressed with the results of the transition, that they have ordered an upgrade to the X-ray system used for pre-op screening and chest X-rays and are going to upgrade all of their outpatient facilities to DR in the near future.

"The economy being in a state of uncertainty has caused many hospitals to cut or eliminate the purchase of new radiographic equipment," said Voegtlin. "Although this is a challenge, our ability to upgrade existing systems with DR retrofits has helped hospitals keep up with cutting-edge technology while eliminating the capital expense of a whole new system. The beauty of this is that the DR system can be moved to a new system when the facility budgets for one. This alternative has been received very well by facilities in our area, and allows for a very financially sound investment."

Most in the industry believe that DR will eventually make CR obsolete, even though the costs associated with the technology are much higher.

"I think the big attraction of getting rid of film is that images can be transmitted with great detail from the flat plate technology and then read anywhere in the world and transmitted back," said Mark Ardoin, Owner of Omni Imaging Service.

Creating the R/F Room

For hospitals creating an R/F room from scratch, it's important to consider flexibility and upgrading capabilities for the future.

"I think people should think about 'Am I just buying a room for today or am I designing a way to manage patients and do I want products that are upgradeable, that will get into technologies that can retrofit in my current investments and allow me to expand far beyond just one level of product release?'" Burkhart said. "To create an R/F room within this market, it's always a question of cost vs. price. You can always go cheaper, but I think you have to be asking what you are giving up in productivity."

Treusdell advises setting up the room so it's flexible enough to do both radiographic and fluoroscopy procedures in digital formats that are integrated, letting the patients get in and out faster.

Refurbish and Service

When it comes to refurbishing the systems, it takes a company with experienced engineers to get the equipment back to OEM specifications.

"No two machines are alike but the basics are always going to be cosmetics and batteries," said Gugel. "But you need someone who knows what they are doing as far as the electronics and the boards go. For example, if you don't charge it for a month, the charger board can go dead."

Mechanical parts that might compromise the structural integrity of the equipment should be replaced, as well as components that can reduce the radiation output of the equipment.

Radiographic equipment refurbishing involves overhead tube stand safety reels and counterpoise assemblies checked and replaced if worn or out of date, and the replacement of tube stand bearings and brakes as well as patient table locks and bearings.

R/F unit refurbishing is more complex, with the imaging system usually overhauled with new camera tubes or intensifiers.

Bill Adkins, President of National X-Ray Corporation said there are a lot of good X-ray tables available and servicing or refurbishing them is normally fine.

"A lot of times they just need bearings and we'll paint it and then we'll upgrade the electronic parts of it with a new high frequency X-ray generator, new tubes and cables," he said. "The service business is increasing because everyone is fixing, rather than buying."

Based in Florida, the company sees a great deal of lightning damage that has caused problems with the X-rays. User error also accounts for problems.

"People are always dropping something on a tabletop and busting that and damaging equipment," he said. "A lot of the damage is done because of electrical damage or someone making an error or running something into it."

Ardoin recommends a yearly PM on the equipment and notes the most common service problems include board replacement and maintaining the high voltage cables.

"They need to keep it clean and wrap the cables up loosely to keep them lasting longer," he said. "For an R/F room, there are a lot of moving parts on the table that need to be maintained."

Looking Ahead

Burkhart said that the most important advancement out right now is in wireless technology, but expects the integration of IT multimodality imaging and better information tools to be expanded in years ahead.

"Wireless is really hitting the market and it can enhance the workflow. You have a wireless plate you can move into a standard X-ray room and move it anywhere within the room," he said. "Our first installations show that workflow impact is quite promising and favorable."

Hybrid rooms are also expected to become popular with the combination of D/R and R/F rooms.

"You'll have one geometry, but two different technologies that can operate in the same room," Burkhart said. "Soon, there will be plates coming out to the market that will accommodate that as well, which will really help increase utilization."

---

DOTmed Registered Radiographic, Rad/Fluro Equipment Sales & Service Companies
Names in boldface are Premium Listings.

Domestic
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
Daniel Giesberg, American Medical Sales, CA
DOTmed Certified
Stephanie Espinola, JCF Engineering, Inc., CO
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified/100
Samuel Sandlin, A.M. X-Ray Service, FL
DOTmed Certified
Woody Peters, Amber Diagnostics, FL
Bill Adkins, National X-Ray Corporation, FL
DOTmed Certified
Mark Ardoin, Omni Imaging Service, LA
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Michael Wray, RadSource Imaging, MO
William Brooks, Salem Medical Electronics, Inc., NC
Patrick Helms, Troff Medical Services, NC
Robert Mace, Alexander Medical Imaging, NC
Christi Kukes, DMS Health Technologies, ND
Alison Fortin, Global Inventory Management LLC, NH
Robert Manetta, Nationwide Imaging Services, NJ
DOTmed Certified/100
Won Choi, DRGEM USA, NJ
Tony Iurato, A Walsh Imaging, Inc., NJ
Joseph Jenkins, International Imaging Ltd., NV
Ronald Blue, SouthWest Imaging, Inc., NV
Leon Gugel, Metropolis International, NY
DOTmed Certified/100
John Kollegger, Bay Shore Medical, LLC, NY
DOTmed 100
Steve Stepanski, Express Systems & Parts Network, Inc., OH
DOTmed Certified/100
Steve Hurley, ProActive Technology Solutions, OH
Pete Schliebner, Benchmark Imaging Group, OH
DOTmed Certified
Tim Austin, Austin's X-Ray Service, OH
Michael Profeta, Magnetic Resonance Technologies, OH
DOTmed Certified
Michael Lies, Medical Advantages, Inc., PA
DOTmed Certified
David Hurlock, Varian Medical Systems, SC
David Wingo, Radiology Equipment Partners, TN
David Voegtlin, Diagnostic Excellence, TX
Courtney Lane, Innovative X-ray Services, LLC, TX
Joseph A. Nelsen, JOJ-XRS, TX
DOTmed Certified
Charles T McDonough, Premier Imaging, Inc., TX
Scott Burkhart, Philips Healthcare, WA

International
Samir Allahverdi, Intermedservice, Azerbaijan
Bruno Vandelanotte, Vandelanotte, Belgium
David Lapenat, Anda Medical, Canada
DOTmed Certified/100
Fred Fischer, FMS X-Ray Services, Canada
Abdelrahim Ibrahim, Besisc, Inc., Egypt
Rajinder Singh Kanwar, Allengers Medical Systems Ltd, India

---