With direct radiography prices falling substantially in the last year and a half, is it safe to say that the predictions made years ago are finally coming true and computed radiography is officially dead? Well, the answer remains as it did in years past, according to some experts – the technology is still tenaciously, if precariously, hanging on.

Because DR imaging enables much faster patient throughput and imaging processing, there’s little dispute among experts that facilities and hospitals will eventually move toward DR in the long run. However, as hospitals face reimbursement cuts and steep financial challenges moving forward, they’ve taken steps to minimize cost, which has meant slow adoption of expensive DR updates. However, with the arrival of affordable retrofit solutions that can turn existing analogue rooms into DR units, hospitals can now choose from a flexible array of options to meet their needs.


Decisions, decisions
According to Ueli Laupper, director of digital radiography of the Americas at Agfa, the decision about whether or not to invest in DR technology ultimately hinges on one major factor: patient volume. “If you have low volume — if you only do five to 10 X-rays a day in a chiropractor’s office or veterinary clinic, you will not be able to make back the investment by going DR — you are better-served buying a CR system. CR technology has dropped in price significantly in the last few years. Given that, a customer will make the decision based on how much volume they have.”

According to Viola Fernandes, product manager for Siemens Healthcare, it depends on whether hospitals already have the CR readers and cassettes — if they do, they usually continue to go with CR. Occasionally she sees facilities that make a full-fledged commitment to DR out of a desire to keep in step with other hospitals: “Sometimes a hospital will say, my competition is upgrading their technology and I want to compete — that may motivate them to switch to digital.” Fernandes says a hospital with one DR room already may be more willing to make further changes after seeing the benefits.

Yet, with the price slashing in the DR sector over the past few years, even smaller non-hospital facilities with significant traffic are beginning to adopt DR and that shift is being felt throughout the industry. “Right now as a dealer, 70 percent of our volume last year was still CR. This year it’s probably going to be 60 to 50 percent — overall there’s a stronger and stronger trend toward DR,” says Yvan Degomme, owner of Proximus Medical, a refurbishing company that sells both CR and DR machines.

One strong proponent of DR is Bill Broaddus, director of radiology at Central Baptist Hospital, who was so satisfied with his Siemens DR Multix M machines that his hospital was the first in the U.S. to buy Siemen's wireless Ysio model in 2008. "It enabled the staff to be more efficient,” he says. “They didn't have to take the CR plate, go back to another room, put it in the reader, and electronically take the image off the plate." Broaddus hasn't had to add staff since 2003, and estimates that his department's workflow became 20 to 40 percent faster thanks to going DR.

Though DR offers many improvements in workflow, there are also a few specialized areas in which CR still dominates. For example, long-length imaging still presents a challenge for DR X-rays, most of which have standard-sized detectors that can’t capture the full length of the body. Because CR cassettes come in different lengths with multiple plates, technicians are able to take the X-ray in one shot by overlapping several plates together. “With DR detectors, there’s no way to overlap imaging plates or detectors ,so you have to take two, three, or in some cases, five exposures for one long length image compared to CR, which is one image,” explains Rob Fabrizio, director of marketing and product development of the digital X-ray division at Fujifilm. “In between exposures, the patient may have moved and the images may not be lined up.”

The same goes for scoliosis exams, which require X-rays that span the full length of the spine. “You’re capturing from maybe from the floor to their hips, or from their neck to their waist,” says Fabrizio. “Because all scoliosis exams are pediatric, pediatricians are especially concerned with not exposing their patients, who are usually 15 and under, to too much dose.”

But this begs an obvious question: won’t DR quickly catch up with the few areas in which CR still holds an edge? Although a number of OEMs including Fujifilm, Konica Minolta and Shimadzu offer DR auto-stitching technology to facilitate wide-range images, it hasn’t cannibalized the CR market yet, according to Fabrizio. “Hospitals that do frequent scoliosis exams prefer CR, hands down,” he says. “There’s a higher than expected demand for CR cassettes – we’ve sold a lot of scoliosis cassettes over the years and expected that number to drop off with DR. We’re seeing the demand for the CR stitching starting to go down, but not as much as expected.”

Dose of controversy
Even discounting efficiency, there’s at least one hot-button issue that’s tilted in DR’s favor: dose reduction. In 2009, 269 patients at Cedar Sinai Hospital undergoing CT exams received eight times the necessary radiation dose. The incident received coverage from major news organizations including the New York Times, resulting in widespread outcry from patient advocate groups.
In response to the controversy, California passed the Radiation Overdose Act, which requires that radiation dosage levels from CT scans and therapeutic X-rays used to treat cancer be tracked in patient health records. It went into effect on July 1, 2012. The incident has created wider ripples in the imaging industry as a whole, spurring greater public scrutiny and awareness over the use of dose.

DR machines offer a distinct advantage for the dose-concerned, as their detectors use less dose on average than CR machines and also offer more ways to adjust dose parameters depending on the type of exam. Consequently, Laupper sees a wave of growing interest in technology that provides dose reduction: "When you talk about technology to a radiologist today, they are also focused on the applied patient radiation dose – especially in hospitals, pediatric environments and imaging centers. I see the same importance being placed on radiation dose in the U.S. as it has been for years in Europe going forward.”

Siemens’ Fernandes agrees: “Dose is a really big topic right now. That’s part of why detectors are being widely accepted in the market. All CR vendors — if you look at Konica, Kodak/Carestream – there’s a reason why these companies are moving to detectors. Detectors use much lower dose compared to CR, and there’s a larger movement toward dose awareness. “

According to Fabrizio, more experts in the industry are pushing to build international standards that are accepted globally from one manufacturer to the next. Not only would radiologists in different countries calculate dose in the same way, but ideally, they would also be able to keep track of the total amount of dose that patients receive over their lifetimes.

Going retro
DR systems have another major workflow advantage that’s proved indispensible for high-volume hospitals: digital RIS lists. These lists provide instant access to health records, such as patient information and exam schedules, within the X-ray system. “These RIS lists populate the machine with kV and mA requirements and other technical parameters so all the technician has to do is point and shoot,” says Fernandes.

According to Stephen Holloway, senior analyst at InMedica, the widespread adoption of PACs has played a significant role in DR’s momentum in recent years: “A lot of uptake has been brought on by increased use of health care IT—integrating PACs with the X-ray system has brought gains for workflow in many facilities in DR. Paired with near-instant processing, that’s the biggest factor we’ve seen.”

Now, in response to growing demand from customers, CR vendors are offering solutions that meet somewhere in the middle, providing a way for customers to take advantage of the efficiency and throughput gained with DR by retrofitting their existing equipment with shared detectors for a fraction of the cost.
Laupper explains that Agfa is one such manufacturer: “What we offer is the choice to retrofit rooms by offering a detector that can work with any X-ray system out there - independent of the manufacturer - for very little capital investment.” He notes that their retrofit NX workstation includes their proprietary MUSICA2 software, which optimizes image quality by automatically modulating image density and contrast.

Holloway observes that with upgrade kits priced around the $60,000 to $80,000 range, retrofitting is an increasingly attractive option for cost-conscious facilities that might have been put off by high initial prices before: “Over the last three or four years, we’ve seen the prices of panels drop from 8 to 10 percent a year—with these panels applied to retrofit kits, we see big potential for future market growth."


Updates and upgrades
As DR increasingly dominates the X-ray market, where is the technology headed next? In the near future, at least, customers can expect to have access to a wider range of DR detector sizes. Standard-sized 17 x 17 and 14 x 17 DR panels are not suited for certain specialized imaging exams. Broaddus gives one example: "In the neonatal intensive care unit, they're putting these microcatheters through the umbilical cord, and you don't want to move these neonates. With a smaller plate, you can put it under the table in a tray and the image can be immediately viewed by the physician on the portable monitor." Many manufacturers have either already added compact detector sizes to their product offerings or are in the process of releasing them.

Another future trend to watch for in DR, according to Degomme, is rapid capture framing for arthritic patients: “Using this technology, doctors will be better able to pinpoint the precise location of arthritic pain by seeing how the pain interacts within the patient from frame to frame.“

So what will the future of CR look like in the near-term? Degomme predicts CR will move toward “less costly platforms, nimbler machines, fewer moving parts, less breakdown – that’s the only way CR will continue to play an important role in the market.” Meanwhile, experts agree that multi-plate cassettes that originally catered to high-volume customers will continue to see a decline as more facilities are able to purchase digital rooms or convert existing rooms.
However, for many facilities looking to cut costs, CR may still be a viable option. Frabrizio says, “The majority of hospitals are unquestionably continuing use of their CR and converting to DR in small steps.”

Agfa’s Laupper makes a bolder prediction: “CR and DR technology will be coexistent and complementary for the next 20 years – depending on the market segment as well as the geography.”

DOTmed Registered DMBN February 2013 CR,DR Companies

Names in boldface are Premium Listings.
Domestic
Jack Pollock, Absolute X Ray Solutions, CA
Bill Payne, Freedom Imaging, Inc., CA
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
DOTmed 100
elie semaan, Rayon-x Engineering, LLC, CA
Amber Trombley, GE Walker, Inc, FL
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
Ed Ruth, Managed Medical Imaging, FL
DOTmed Certified
Bill Adkins, National X-Ray Corporation, FL
DOTmed Certified
Scott Wasson, Radiology Services LLC, IN
DOTmed Certified
Kevin Fix, Ultimate Medical Services, Inc, LA
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed Certified
DOTmed 100
Mudi Ramesh, Anamika Medical, NY
DOTmed Certified
DOTmed 100
Robert Muzzio, GXC Imaging, NY
George Girgis, Meena Medical Equipment Inc., TX
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International
Mads Vittrup, AGITO Medical, Denmark
DOTmed 100
Benjamin Balagtas, Bullseye, Philippines
Carlos Duran, INGENIERIA CLINICA, Colombia
Isaak Vainstein, Biotehnik OU, Estonia