This article is from in the February 2008 issue of DOTmed Business News. A list of registered users that provide sales & service can be found at the end.

The use of film X-rays is being phased out and replaced by digital alternatives including high-speed DR and more affordable CR systems. Market forces such as the high cost of film, which contains raw materials including silver, and concerns over the environmental impact of chemical processing, are among many factors pushing health care providers over the digital divide.

The shift toward electronic medical records and the growing use of PACS systems are also intensifying the urgency to convert imaging studies to digital formats and systems. An ever-present need to cut costs, particularly with today's reduced reimbursements, makes CR and DR attractive for their increased patient throughput and more efficient workflow, which digital systems support by removing many steps for technologists performing the study, storing, and transferring images where needed. Of course, radiologists and other physicians can easily obtain remote access to digital files. As though these issues weren't enough to convince providers to switch from analog film to digital CR or DR, some newer technologies also promise to reduce patient exposure to radiation.
There are two ways to "go digital." Computed Radiography (CR) is a simple - and many believe interim step-to replace film cassettes with reusable plates that translate the X-ray image into a digital format. DOTmed industry experts estimate that the current market for new CR technologies supports sales of about 5,000 systems per year. In the more sophisticated Digital Radiography (DR) systems, the image is stored directly and automatically into a digital file. State-of-the-art DR technology provides the fastest performance and workflow with the highest quality imaging available while minimizing radiation exposure during the exam. About 1,000 new DR systems are sold each year.




As far as the installed based, the vast majority of hospitals have some form of CR in place. Yet many major hospitals are still film-dependent. Regarding DR, market watcher IMV estimates about one-third of U.S. hospitals have at least one DR system in their radiology department.

"We see tremendous growth in DR and have a long way to go for full penetration into the market," says David Widmann, Global General Manager of Rad/R&F for GE Healthcare. "The expansion of our digital line is beginning to reach out into different markets and we have a commitment to make those technologies available even in the rural healthcare markets."

"We expect the market [for DR] to grow. It's not going to 'hockey-stick' grow but it's definitely going to continue growing gradually and smoothly across the marketplace," predicts Kevin Oakley, National Marketing Manager for DR, Fujifilm Medical Systems USA. (As of this writing, the company is anticipating FDA approval for its Unity SpeedSuite, a single-detector, value-oriented DR system.)

Many Players in a Crowded Field

More than 40 manufacturers offer over 80 products for digital X-ray acquisition systems, Frost & Sullivan reports. These include the big OEMs, which are DR dynamos such as market leader GE, Philips, Canon and Carestream Health (formerly Kodak), and Toshiba, along with Fujifilm and Agfa. (Fujifilm will discontinue U.S. production of medical film April 1, 2008 but will continue to supply film to customers.)




Some leading-edge OEM offerings include GE's Definium 8000, which among other features provides automatic advanced image processing so technologists don't have to manually paste multiple images together. (GE doesn't produce CR systems.)

Carestream's DirectView DR9500, is a single-detector design that does dual duty with a ceiling mounted U-arm to keep the bucky and tube aligned while it moves around the patient. At the same time, the company remains committed to CR having purchased leading manufacturer OREX in 2005.

"There's no question that we are continuing to invest in our computed radiography portfolio," says Eileen Heizyk, CareStream's Worldwide Marketing Manager for CR. "Some of the higher-end parts of the market are more saturated and may be moving more to DR, but there is certainly plenty of growth and opportunity in the smaller facilities value tier."

Virtual Imaging, Inc., Deerfield Beach, FL is a Canon authorized distributor that specializes in upgrading facilities from film straight to DR. "We can go into any facility and upgrade to DR without dismantling the room, and get equipment to OEM specs," says Kris Kessler, Creative Marketing Director. "We skip the CR aspect and go directly to DR." This is possible because of the versatility of the Canon CXDI-50G Digital Radiography System, which is compact yet large enough for chest and abdominal X-rays.

Many smaller manufacturers offer a number of niche products to meet nearly any budget or application.




One example is Alara, Inc., which makes CR systems. Their T-Series is a drum-based, compact tabletop CR. "It's inexpensive, rugged, and easy to use. We sell a lot in veterinary and in human health care applications, particularly in the podiatry and chiropractic markets," says Kuldip Ahluwalia, V.P., Sales and Marketing, Alara, Inc., Fremont, CA. "The beautiful thing about CR over DR is it's a stand-alone device. It's easily upgraded from your standard X-ray scanner. There is no workflow difference and it's an inexpensive way to move into the digital world."

Another niche company is Torrance, CA-based iCRco, Inc., which offers a CR technology that also promises to tamp down the cost of ownership of digital X-ray while overcoming some inherent CR design challenges. The company's True Flat Scan Path technology ensures that nothing ever comes in contact with the active area of the costly phosphor plates, producing 500,000 or more artifact-free images for the end-user with no degradation in image quality, according to the company. "True Flat Scan Path is the first thing an end-user should look at when transitioning to the digital environment," suggests President and CEO Stephen Neushul. (The company also has a DR offering.)
Independent service providers sell and service systems made by the smaller OEMs, an arrangement that can save significant costs.

Sal Aidone, Vice President, Deccaid Services, Deer Park, NY, sells CR systems made by iCRco, Radlink, and Konica Minolta, as well as OREX. "Independent companies like us and the smaller suppliers can drive down costs as long as the customers don't have the mindset that they have to buy from the large OEMs. They need to look for quality instead of just a name," Aidone says.

The costs for new CR systems depend on the manufacturer and features and range from about $40,000 to $60,000 for a small system for an imaging center, up to $90,000 to $120,000 for large, high-end, multi-slot, hospital-grade CR. DR requires a more significant investment starting in the six figures. Entry-level DR can go for $200,000.

If all this sounds too expensive, consider some hidden costs of film. "Typically there's sticker shock when people hear about pricing for the new CR systems, but they have not done their homework in terms of factoring the cost for producing one single film, let alone a study of three to four films," says Michael Lies, President, Medical Advantages, Inc., Pittsburgh PA. "In addition are costs such as courier service to doctors off-site and the cost of lost films and repeat studies [which digital solutions eliminate]. "If [customers] do their homework, they are not in shock when they hear competitive pricing for CR systems."
As hospitals and imaging centers upgrade to new CR or DR systems, the used CR systems are put to good use.

"What we are finding is hospitals are expanding the use of CR. They seem to be shuffling equipment around. They might put in a DR room but they don't get rid of their CR, they are moving it to another department or an off-site imaging center," reports Heizyk. "There is a lot of competition among hospitals to participate in the imaging center market and make it easier for their patients. We are finding they are moving CR [to imaging centers offsite] or adding another [CR unit] to an existing department."3

In other cases the used equipment becomes available on the market, providing another cost-saving opportunity. Expect to pay around $20,000 to $30,000 for refurbished single-slot CR systems and $35,000 to $40,000 for refurbished multi-slot CR. Be sure your system includes the computer hardware, software, and cassette reader and viewer; and is brought to OEM specifications and supported with a warranty. (Few used DR systems are on the market and supported with warranties.)

Time to "Go Digital"?

There's a growing consensus that it makes economic sense to convert from film to a CR systems in most cases. "Film will soon be a thing of the past with CR the low-cost solution in the market," predicts Kessler.

Here are some other suggestions from DOTmed users and industry experts: You know it's time to go digital when..."the costs of film, transportation of files, filing and storage, chemicals, duplication, lost films, plus the hassle of not having the files at the doctors' fingertips exceed the cost of the new system," says Mark Kladivo, Broker, pcCentral, Urbandale, IA.

"When you consider the direct and indirect costs of film, going filmless just makes sense," says Scott Wasson, President and CEO, Radiology Services LLC, Evansville, IN. "Practically all CR systems are more reliable than film processors."

At the same time, the decision must be driven by your particular needs and budget constraints.

"It only makes economic sense to switch [from film to CR or DR] when the cost of the system is less than the cost of chemical processing. It depends on each facility, the volume of images and the reimbursement," advises Donnie Torok, Business Manager, Beach Medical Imaging, Indian Harbour Beach, FL.

CR vs. DR

When should you invest in CR versus DR? Industry insiders predict that CR will continue to dominate the market for the next three to seven years but that DR will gain ground thereafter. Most hospital radiology departments have some combination of CR and DR, along with their older film systems. Generally, CR systems are more affordable for imaging centers and private practitioners, and even small and community hospitals, while larger institutions or groups consider investing in DR.

"When you have 100 films per day then DR will make sense. If less than 100 films per day then CR is a good choice," suggests Samuel Sandlin, owner of A.M. X-Ray Service, Miami, FL.

"I don't think CR pricing can go much lower so it's a step between film and DR. But if you don't have a real need for super speed then you really don't need a DR. It's just for hospitals that want the latest and greatest," says Aidone. "I would rather have a new CR than one of those older DRs. It would be faster and the technology is more up to date."

"CR is leading the way into the filmless future. If a facility has a mid- to high-volume throughput and intends to stay in business more than two or three years, then it is irrational not to go with CR. DR, still being very expensive, has yet to secure a major market share," says Joseph Jenkins, International Imaging Ltd., Henderson, NV. He stresses the difference in priorities for large and small healthcare providers. "When you're spending other people's money, you can buy DR, but when you're spending your own money you have to be more practical."

"The larger institutions that are well funded tend to buy the leading-edge technology whether or not they really need it," says Greg Cefalo, U.S. Digital Radiography Business Manager, Agfa HealthCare. "For-profit hospitals are not as well funded and they really have to scrutinize that decision for CR and DR....It's still quite difficult to beat the value of CR."
Still, DR is the cutting-edge X-Ray technology, coveted by clinicians of many specialties. In fact, access to in-office digital radiography (and MRI) capabilities are among U.S. orthopedic specialists' greatest unmet needs, according to IMV. "Digital radiography is a key priority for many orthopedic practices in their efforts to have remote access to imaging results, to better manage large volumes of imaging data, and ultimately to provide more accurate patient diagnoses," concludes Mary C. Patton, Director, Market Research, IMV.
Kessler observes, "With CR the user must replace their CR cassettes after so many uses which incurs additional costs. With DR you do not have to worry about replacing equipment as frequently. Digital detectors are more durable and reliable, which extends the life cycle of any existing equipment without any residual costs."

However, there is one application where CR may reign supreme for some time to come. "I don't think CR will go away, it has good applications in portable X-ray," Sandlin says. "I've seen some sites go portable with DR and it doesn't work out as well. It needs to be wireless or everybody runs over the cable. It's easier to use a cassette when you're on the hospital floor or ER. So I think CR will be around a while."

Carestream just launched its new KODAK Point-of-Care CR-ITX 560 System for ICU and portable applications. "We've made it easier for the techs because they can do the imaging bedside. You can tell at that point if you need to take another shot. Or, if it's a critical care situation, get a quick X-ray view without carrying away cassettes to put through a reader. The reader is right there bedside," Heizyk says.

Fujifilm is another OEM well aware of the portable application for CR. The company partnered with Hitachi to create the FCR Go digital portable machine. This device also allows the technologist to see immediately whether the X-ray position was correct while on the unit floor with the patient. Images go straight to PACS and the design eliminates the need for re-training for technologists since its interfaces are consistent with prior technologies'. FCR Go is expected to earn FDA approval and become available in the U.S. in mid-2008.

Some of the newest innovations combine the best of both worlds -- CR's ability to position the detector freely and DR's instant image access and high resolution. Agfa's DX-S cassette-based X-ray system can be used for any number of exams yet offers DR-like workflow-perfect for a trauma setting.
Also on the horizon is a wireless digital detector from Philips that integrates benefits of both CR and DR. The unit will synch with the hospital network and integrate with PACS at the push of a button.

Another trend is toward automation of, e.g., multiple spine images for faster studies with less wear and tear on the technologist. For instance, Toshiba's dual detector RADREX receives instructions for body part mapping directly from RIS information and imports work lists for the particular patient and study. The technologist doesn't have to find settings for, say, a chest or abdominal X-ray. These and other innovations mean that those who have delayed the decision to go digital may leapfrog ahead of other providers. And by waiting, prices have come down that put not just CR but possibly DR within reach.

"From a DR perspective, one of the things that's happened in the last five to ten years is that a lot of people who were going to buy new X-ray equipment held off those decisions so that they could buy other kinds of high-end technologies such as MR and multi-detector CT," Oakley says. "What's happening now is they really can't wait much longer."

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DOTmed Registered DR & CR Sales and Service Companies
Names in boldface are Premium Listings.

Domestic
Sal Aidone, Deccaid Services, Inc., NY
DOTmed Certified
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
Samuel Sandlin, A.M. X-Ray Service, FL
DOTmed Certified
Donnie Torok, Central FL Med Equip, FL
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified/100
Kris Kessler, Virtual Imaging, Inc., FL
Mark Kladivo, pcCentral, IA
Scott Wasson, Radiology Services LLC, IN
Joseph Jenkins, International Imaging Ltd., NV
Tim Austin, Austin's X-Ray Service, OH
Peter Chen, Global Medical Equipment, PA
DOTmed Certified/100
Michael Lies, Medical Advantages, Inc., PA
DOTmed Certified
Paul McCabe, Peterson Imaging, Inc., PA
Will Martinez, Trident Imaging Services, TX
John Snyder, Cal-Ray, Inc., WI

International
Maciel Passarelli Ramos, Construtec Rio Comercio Ltda, Brazil
Wang Zhixuan, Hangzhou office of Huaxin Co. Ltd., China
Abdelrahim Khalil, Besisc, Egypt
Mike Gergatsoulis, Technomedical, Greece
Alejandro Rodriguez, Interfase-Medica, Mexico
Mohammad Shuaib, Image Vision, Pakistan
Florin Anghel, AmediT, Romania
Theera Sirinawee, Welldone Solution, Thailand

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