This report originally appeared in the March 2010 issue of DOTmed Business News

When digital flat-panel radiography was launched just a few years ago, many thought it would take over the imaging world. It has certainly made its presence known, but total conquest hasn't happened just yet. CR is still the workhorse in many radiology departments, but more competitive pricing and recent developments in DR technology, including the advent of wireless detectors and retrofit kits, are giving DR a lot more momentum.




Sales in X-ray including both CR and DR has slumped during the past two years, but some suggest a better outlook in this sector by the end of the year.

"The X-ray market was probably down by 20 percent and the digital market was probably down by a little bit more than that, depending upon what area, but we saw significant declines across the board in 2009," says Scott Burkhart, vice president of general X-ray for Philips Healthcare. "I think hospitals really tried to preserve capital and that really slowed down the tidal wave to digital that we had seen in years past."




"Sales are about where we expected, maybe even a little stronger than what we expected, in light of the economic situation," says Eileen Heizyk, worldwide marketing manager for Carestream Health. "I think everyone has prepared themselves for the worst, but we do see a lot more interest now that people are looking at their 2010 budgets."

New technologies gaining recognition

According to market research from well-known firm Frost & Sullivan, Carestream Health is on a land grab for DR market share, and with the introduction of the DRX-1 wireless flat-panel detector in the spring of 2009, that trend is expected to continue.

EDGE Medical Devices, another prominent company in the DR world, received Frost & Sullivan's 2010 award for Enabling Technology. The award was associated with EDGE's proprietary plasma flat-panel detector. In most flat-panel detectors, procuring electrical image data from X-ray radiation usually requires an intermediary conversion of radiation to visible light. The scintillating elements, usually gadolinium oxysulfide, cesium iodide and amorphous selenium, produce the visible light that is then picked up by a layer of thin film transistor or TFT elements. The electrical charge is converted into pixel data and transmitted to the hospital network. EDGE's Plasma DR technology uses selenium, but has replaced the TFT with a virtual pixel array, which not only brings down manufacturing costs and the overall price point, but it just might prove to be more robust than other technologies without compromising image quality.

The price is right-almost

Flat panel technologies are still very expensive, but the price is finally coming down. In the past five years, a two-plate DR room has moved in price from $500,000 or $600,000 to the neighborhood of around $400,000. Single plate systems have come down in price by as much as 30 to 40 percent. That's not limited to DR. On the CR side, prices are falling just as steeply.




"The price point of digital technology has come down, for both DR and CR, which is healthy," says Rick Sbordone, vice president of sales for Edge Medical Devices. "It's bringing the technology to a larger market segment, and as prices come down, more people can adopt it."

DR in the ER

One of the places where DR has really taken off is in the ER, where everything is time sensitive and procedure volume is high. DOTmed met with Royal Liverpool and Broadgreen University Hospitals NHS Trust superintendent radiographer, Steven McDonald, who presented a scientific presentation titled "DR in the ER" at the 2009 RSNA Annual Meeting. He had some interesting things to say about digital radiography and how it is changing the game in the emergency room.

The Royal Liverpool and Broadgreen University Hospital is an 800-bed acute care and city center hospital. They use Carestream's fixed DR 7500 radiography system. Radiologists can have the patient in and out in 30 seconds from a procedure point of view - but it's not always about speed, says McDonald. If they have five minutes allotted for that patient, the rest of that time could be spent caring for the patient and allaying fears. McDonald relayed a recent case of a patient who fell 70 feet after a construction crane had collapsed.

"Can you imagine that poor guy - you're walking off with your CR cassettes or analog images and you're putting them through a processor and he's left on his own, lying there, neck strapped down, not knowing what's going on," said McDonald. "We don't have to do that anymore and that's what makes it exciting in the ER."

But is DR cost-effective? The Royal Liverpool and Broadgreen University Hospital has had DR for a little more than two years. The hospital used to have three X-ray rooms and a CR system with conventional X-ray tubes. They were seeing 22,000 patients per room annually. Now they have taken it down to a two-room DR set-up, and are seeing 33,000 patients a year, a major uptick.

"The other thing that goes in tandem with that is we used to have seven radiographers in those three X-ray rooms," says McDonald. "We've now been able to release three radiographers to go and do CT, MR and ultrasound in other departments. On an average day, the radiographers are doing 30 patients per radiographer where they used to do 17."

McDonald's scientific presentation dealt with differences in procedures between analog images, CR and DR and how to properly position and image tricky anatomy.

"What you do is, you get your textbooks and you throw them away and start from scratch," he says. "We're now imaging our elbows slightly differently and our knees slightly differently, our facial bones and our chest X-rays slightly differently. They all need a little personal tweak on them."

The art of image exposure has been transformed from a largely intuited "touch and feel" process to what is, for the most part, a touch of a button today. With the help of PACS and RIS, patient information such as exam type, weight and age are preloaded and used to capture the perfect image, or the closest thing to it.

"With this technology you don't have to worry as much about exposure and there are very few retakes with DR, a few more with CR and about 5 to 10 percent in film," says Burkhart. "Image quality is much better with DR because everything is optimized."

DR retrofits grow in popularity

An estimated 60 to 70 percent of major hospitals have purchased at least one DR system, but for those utilizing CR or analog rooms without the capital or intention of outfitting a whole new DR X-ray room, the retrofit is a more cost-effective option. If you're in the market to convert an existing analog room, or even mobile unit, good news-many major manufacturers are now offering something along these lines.

"Solutions like this are perfect for facilities that want to improve workflow and see more productivity but can't afford to replace an entire room - and they don't have to," says Heizyk. "I think the way things are in the marketplace today, folks want the ability to have very versatile and flexible solutions as well as something that's modular where they can replace just the part they need to replace this year."

Carestream's DRX-Evolution suite is a modular system of equipment intended to replace all or some of the traditional X-ray room. It includes the DRX-1 detector, a table, wall stand and console. For many, retrofitting can mean a quarter of the cost of doing a whole new room. It's a three-to-four hour install completed same day.

The majority of the facilities that have really caught on and embraced DR are the university and large teaching institutions with the patient volumes to warrant the investment. Mike Foley is director of radiology for Tufts Medical Center, a 450-bed academic teaching hospital in downtown Boston responsible for about 186,000 X-ray exams per year. He recently converted one of his analog X-ray rooms to a wireless DR system using the DRX-1 technology. This particular part of the hospital system images about 120 to 140 patients in a compressed six-hour day.

"It was an area that was extremely busy," says Foley. "I was faced with the idea of potentially having to build a third X-ray room out, but we thought that if we worked on efficiencies and put the DR system in there we may not have to and it worked out really well. The technologists grabbed onto it really quickly, the image quality is fantastic and our radiation dose, as compared to CR, has been cut in half."

Conversions like this one can save practices upwards of $1 million in construction and capital costs, and going for a retrofit is about 20 percent of the cost for a new fixed unit.
Many manufacturers offer any number of upgrade packages. Philips, for instance, offers 150 different options, including the company's high-end DigitalDiagnost flat panel system with optional wireless detectors.

"Clearly in this economic environment more and more people are trying to stretch their dollars and they are in many cases looking at upgrades, whereas normally hospitals would use their systems for 10 to 15 years and then replace them," says Burkhart. "New digital technologies are so much faster and better, but if you don't have the money to expend $300,000 to 500,000 on a system.... you can get a least a half step into digital, either CR or low-end DR, and a lot of people are looking at that."

Choosing what's best

The choice between CR and DR appears to be a balancing act between two equally valuable technologies, and there are plenty of differing opinions. One thing is for certain - analog is fading fast from the modern hospital.

"Film is less than 10 percent of the market; the real battle is between CR and DR," says Burkhart. "Each one has their tradeoffs and advantages, but I would say both are alive and well in the market. If people have the volume, DR is clearly the better choice because of image quality, dose, throughput, efficiency and payback. CR, on the other hand, is a highly flexible technology that will give you an acceptable image and it will do it much more economically."




The most obvious disadvantage of DR technology is its price. There were high hopes when the technology first emerged, but the economy has been stunting growth in more recent years.

"The projections were that they would far outsell CR at this point, but that has just not been the case," says Penny Maier, director of marketing for Imaging Systems at Fujifilm Medical, a leader in CR for many years. "CR is probably still three to one over sales of DR, but that number is catching up more quickly as the price comes down."

Many see the hospital market as being CR-saturated, with most new hospital sales attributed to replacement or expansion of their current technology.

"The way the market is going with CR, we see a lot more being placed into the non-hospital segment - the smaller facilities, the private practices, the imaging centers and clinics," says Heizyk.

What are the disadvantages of CR? Imaging speed can be anywhere from 30 to 50 percent faster with direct-capture methods, and you cut out the middleman, but hospitals that have a lot of different X-ray sites and are less centralized may find that CR works better.

Another possible disadvantage of DR is the high cost after the first five years or so. For Medrad, a Pennsylvania-based medical supply and service company which deals with Carestream, Agfa and Fuji systems, offering service for DR units may be on the horizon, but for now it's all about CR.

"Medrad is focusing on film processors in CR," says Nick Hersman, associate product manager for Medrad. "We're noticing in the market a slow transition from CR to DR because of some of the higher capital investments required to transition."

It's all digital

Let's not get confused. When we talk about CR and DR, it is important to remember that we aren't talking about a completely different modality. The two are more alike than dissimilar.

"CR is a form of digital technology," says Werner, marketing manager for Digital Products at Konica Minolta. Werner explained that the term "DR" is something of a misnomer, because while CR technology is essentially cassette-based and read by a laser scanner and DR uses direct-capture technology with fixed or wireless flat panel technologies, but technically, both are digital.

Direct-capture technologies are just one of the options available. The majority of those interviewed and surveyed said CR accounted for the lion's share of upgraded X-ray technologies, and some very large teaching hospitals have implemented CR and have no interest in going to direct-capture technology any time soon.

"The original wireless cassette was CR," says Maier. "There was this suggestion that you're also going to need the flexibility of the cassette. It was a natural evolution over to a portable-type detector."

Both Fujifilm and Konica Minolta offer flat-panel technology, as well. At RSNA 2009, Fujifilm debuted the FDR D-EVO detector, pending FDA approval, and Konica Minolta introduced the company's Xpress DR system with both fixed and portable detector options.

Wild about wireless

Much of recent research and development in direct-capture technologies is in the wireless realm. Wireless systems are getting a lot of attention, but there is still a lot of work to be done before long-range wireless DR becomes a reality.

"Most big hospitals are getting very crowded in terms of wireless traffic," says Burkhart. "There are any number of ambulatory monitors and systems and things going on, and this is medical data. You don't want to mess it up or have it corrupted."




Philips phase I wireless technology works within a lead-lined room that keeps the signal contained from plate to console and within the confines of the X-ray room, but Burkhart says the future may be in wireless DR that connects straight into the hospital information system.

"When you start to go into the hospital network then you get into the relays and switches and routers and all of these other layers of handoffs have to happen and they need to be controlled. There's a lot of know-how involved."

Still, this kind of technology may be less than two years off, says Burkhart. "Just think-how quickly did we assimilate wireless into our personal lives with the cell phone? Once we got it and once the network was able to do all the handoffs, it worked quite well. I think it's the same issue in the hospital. The only difference is you are dealing with life science and people's lives and liability. You just can't afford to make a mistake."

One of the major questions that will need to be answered is in regards to the next generation of wireless and how DR data will be transmitted without interfering with other wireless resources in the hospital environment.




"It may be better for us not to use the existing spectrums that the hospital is using but our own special spectrums," says Burkhart. "Let's say it's 10 megabytes for an X-ray. With telemetry monitors you may have a couple of bits here and there, and X-ray comes along and we start shooting these cannons - huge volumes of 10 MB images through these networks. If you do it often enough, you could degrade that network."

Wireless mobile

A brand new development waiting on FDA approval is a wireless application for portable X-ray systems. Eastern Diagnostic Imaging (EDI) of Taunton, Mass., just announced that they are now the sole distributors of the i5 Mobile DR upgrade for portable GE Healthcare AMX-4 or AMX-4+ X-ray units. The upgrade is the result of a partnership between EDI, Infimed and Carestream. The i5 Mobile includes a wireless DR detector, tablet PC, and Infimed medical imaging platform. If approved, this upgrade kit could mark the beginning of tetherless direct-capture technology for mobile X-ray. EDI President Steve Walsh says the system may be available as early as first quarter 2010.

"It's going to be huge," says Walsh. 'I suspect this will double our business as far as volume goes. Once it's approved, we have a number of demos set-up. Several large institutions with 10, 12 or 13 portables are very interested in this product. It's going to be a very busy year."

Carestream also has their own works-in-progress kit for a wireless portable upgrade using the company's DRX detector. Other manufacturers will no doubt follow suit.

How much of it is hype?

Many in the industry are saying that the buzz about pricey wireless digital technology is mostly hype and high-end novelty, and wireless isn't necessarily a sustainable product in the long run.




"I just think that it's ironic that the industry has gone full circle," says Sbordone. "When digital first came to fruition, everybody wanted to move from cassette-based imaging to no handling of cassettes, and then came this big push for DR imaging. Some of the manufactures said, "Let's make a DR panel that kind of looks like a cassette." Here all of us DR guys find it kind of funny. They weigh five times as much and they cost 50 times as much. Although there is a lot of media hype about it, I think that trend will stop. Those $100,000 wireless cassettes don't make a lot of sense economically or logistically. I really think those are going to be for the guys who like Maseratis and Ferraris, because they're there. We'll have to wait and see."

Productivity is the word

Regardless of the effects of tech-hype and a sour economy, direct-capture X-ray technology is on the path to greater adoption, even if it isn't so much a trail-blaze situation anymore. CR will continue to expand in other segments as DR is increasingly picked up by larger hospitals seeking better throughput with a lower radiation dose. Time will tell whether long-range wireless or wireless portables will be viable.

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

Domestic
Joseph Shafe, Incite Imaging, AZ
DOTmed certified
Kenn Matayor, Jaken Medical, Inc., CA
DOTmed certified
Klaus Kraemer, Multi Imaging Systems, Inc., CA
Ted Huss, Medical Imaging Resources, CA
DOTmed certified
Shane Yaghami, Allied Health Products, CA
Daniel Giesberg, American Medical Sales, CA
DOTmed certified
Penny Maier, FUJIFILM Medical Systems USA, CT
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed certified
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed certified
DM100
Alberto Mencia, Superior Technological Interprises, Inc., FL
Bill Adkins, National X-Ray Corporation, FL
DOTmed certified
DM100
Ed Ruth, Managed Medical Imaging, FL
Kyle Blackwell, Total Medical Equipment, GA
Larry Sprague, UMS, GA
DOTmed certified
Kevin Fix, Ultimate Medical Services, Inc., LA
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed certified
Steve Walsh, Eastern Diagnostic Imaging, MA
Joe Zaremba, Advanco Medical Systems, MO
Harley Warren, Medical Equipment Expense Solutions, NC
Rick Sbordone, EDGE Medical Devices, Inc., NC
Shanna Flanagan, DMS Health Technologies, ND
Joseph Hauschlidt, Metropolitan Medical Imaging, LLC, NJ
Darren Werner, Konica Minolta, NJ
Mike Andrews, Hudson Digital Systems, NJ
Joseph Jenkins, International Imaging, Ltd., NV
Robert Muzzio, GXC Imaging, NY
Audrey Vance, InfiMed, NY
Eileen Heizyk, Carestream Health, Inc., NY
Brett Schaeffer, NHD, OH
Charles Patti, NCD Medical Corporation, OH
Tony Smith, Classic Diagnostic Imaging, OH
DM100
Jim Monro, Radiological Service Training Institute (RSTI), OH
DOTmed certified
DM100
Bob Winters, First Source, Inc., PA
Michael Lies, Medical Advantages, Inc., PA
DOTmed certified
Katie Romano, Medrad Multi Vendor Service, PA
Miriam Ladin, Agfa HealthCare, SC
David Wingo, Radiology Equipment Partners, TN
DOTmed certified
Wayde Keeling, Lone Star X-Ray Services, TX
Courtney Lane, Innovative Xray Services, LLC, TX
Scott Burkhart, Philips Healthcare, WA
Vito Ciparis, Mobile-CR, LLC, WI

International
Prakash Mehta, Shieldalloys India Pvt, Ltd., India
Steven McDonald, Royal Liverpool Hospital, UK

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