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April 26, 2004

Digital Radiography — PACS Helps Fuel DR Growth … but Don’t Bury CR Yet
By Dan Harvey

Initially moving at a rather tentative pace, deployment of digital radiography (DR) systems has increased steadily over the past two years.

Factors contributing to the slow start, observers suggested, included high start-up costs and the natural resistance to technological change. However, the increasing conversion to PACS environments makes DR a more attractive and reasonable option. For one thing, PACS is deemed necessary to DR implementation. Also, the benefits of PACS and DR (eg, increased operational efficiencies, cost-effectiveness) complement each other.

Another interest-generating factor is the reduced prices that typically accompany increased production by manufacturers. (And companies are indeed stepping up production. Canon Medical Systems recently opened a new assembly facility in Japan to meet growing market demand.) Initially, the DR market included mostly the largest institutions—the teaching hospitals and medical centers that could afford the new technology. Now, DR is found in smaller facilities more frequently.

With the increasing implementation of PACS and DR, more facilities are heading toward the sought-after filmless environment. The eventual supplanting of computed radiography (CR) by DR’s direct-to-digital approach appears likely, but CR’s hallmark cassettes won’t disappear anytime soon. To many, CR is still seen as a good introduction to digital technology, especially in some PACS environments, where DR is deemed the next level up.

Digital Benefits
DR and CR haven’t yet completely replaced conventional radiography, but there’s a certain inevitability to DR’s widespread acceptance. Not only is there the PACS factor, but also cost savings and efficiencies produced by DR are not lost on healthcare providers and payors.

“DR is a way to unify and bring general radiography into the 21st century,” comments Antonio Garcia, a senior industry research analyst with Frost & Sullivan, the international growth consulting organization.

Indeed, nearly all other imaging modalities have gone digital. Radiography is coming up to speed, so to speak, and there are many benefits to reap. These include the following:

• Image quality. While DR reduces patient exposure and uses lower dose, the quality of images isn’t sacrificed. In fact, it’s superior. Areas of interest are enhanced while irrelevant areas are eliminated. This makes for easier interpretation. In addition, images are more easily managed and can be transmitted across computer networks and over phone lines.

• Patient safety and satisfaction. Most DR systems use approximately one-half the radiation dose that traditional x-ray systems need. Exam times are sped up because images can be viewed immediately. Also, because the resulting images are easily managed and transmitted, patients can be handled more efficiently.

• Cost-effectiveness. Costs associated with film and processing are eliminated. Because DR systems are so efficient, cost per exam goes down and productivity goes up. “The main benefit we provide is increased productivity,” remarks Renaud Maloberti, manager of global radiology business for GE Healthcare. Studies conducted by GE, he points out, have shown that its products can reduce the exam time by roughly 62%. “For one hospital, that meant saving about $95,000,” he says.

• Increased revenues. Short exam times and greater patient throughput translate into increased revenues. “This is very important, but it often gets overlooked,” says Garcia.

• Operational efficiencies. “You don’t get cost savings from DR itself,” says Garcia. “Rather, savings are realized from workflow reengineering and by going filmless.” DR enables facilities to reduce their number of general radiography rooms. Dark rooms are no longer necessary, and archiving can be done inside a computer. System efficiencies also create cost savings through staff reductions. Sometimes this is where the biggest savings are realized, even more than being filmless. But the potential staffing impact raises a contentious issue, and it saddles DR with one of its biggest challenges. “It forces people to make some tough decisions,” comments Garcia. “Elimination of personnel is not a popular area, even if it can save money.”

Challenges and Barriers
Other challenges present themselves to organizations considering DR implementation. Cost justification ranks high on the list; even with prices coming down, DR remains an expensive proposition for many. The price of DR systems can be twice that of conventional radiography products. Thus, price tags must still be justified to cost-conscious administrations. Doing that entails a great deal of research and analysis—not to mention diligent campaigning. Institutions considering implementation have included in their master plan economic projections and complex cost-savings calculations to help state their case.

Another significant challenge can be the staff’s natural reluctance to accept anything new, particularly if what’s already being used works. “There’s resistance from [other] physicians and radiologists to do soft-copy diagnosis of images. This has played a fairly important role in holding back the market development for DR,” points out Garcia. “Apparently, that is dissolving to a certain extent as people become more familiar with CR, then work their way up to DR.”

However, some users are reluctant to let go of CR. “It’s been out there a long time and has a pretty respectable installed base, and it is significantly less expensive now than DR,” says Garcia.

Still, Garcia believes that DR will eventually supplant CR. He envisions both technologies coexisting for approximately another 10 years as certain marketing forces will keep CR temporarily in the picture. For instance, some PACS vendors currently bundle CR into their packages since it serves as a good introduction to digital. “CR is regarded very much as an entry-level technology, and that is where its staying power will be found in the market,” he explains. “In the next five years, you’ll have 2,000 to 3,000 hospitals transitioning to the digital environment. The big opportunity for CR is as an entry-level solution for those facilities. But, I do think that DR will eventually eclipse CR as the most prevalent form of digital x-ray.”

Infrastructure is another factor affecting DR sales. It is commonly believed that you can’t have a DR solution without first having the kind of digital repository and distribution system offered by PACS or a mini-PACS solution. “You have to have some type of image management system in place to be able to utilize the full digital capabilities of the system,” says Garcia.

PACS Link
Maloberti agrees that DR and PACS go hand in hand. To reap all of the benefits, PACS is absolutely necessary, he says. But, he adds that it’s not entirely pointless to implement DR without PACS. “The productivity benefits will still be there,” he says. “In and of itself, DR is still a good investment.” However, Maloberti says that ultimately, both need to be implemented. “PACS brings it to a new level,” he says.

To help surmount these hurdles, prospective users need a strategic plan that is fully fleshed out—one that is well-researched and forward-thinking. It also needs to be unique. Replicating the implementation model of another facility won’t always work. Cost justifications and implementation plans need to be meticulously detailed. Vendor and product choices need to be well-researched to determine the most appropriate purchase. Every facility is different in its needs and staff profile.

Deployment Case Study
Even though following a replication strategy is not always the approach to take, it still serves well to look at successful implementations. The outpatient facility of the Children’s Memorial Hospital in Chicago has enjoyed the benefits of DR in its radiology department for approximately a year and a half, and its transition ran smoothly.

In its case, the facility brought DR into a PACS environment, while the hospital’s main campus used CR products. Looking for a cutting-edge technology that would interface well with PACS, Ken Gray, RT(R)(CT)(CV), director of imaging, opted to go with DR. “We wanted to bump up to the next level, and digital is definitely that,” he recalls. “We support some busy orthopedic clinics, and the DR solution seemed tailor-made for that.”

As far as cost-effectiveness, Gray knew the start-up costs would be high, but throughput efficiencies helped offset the initial financial outlay. To justify the purchase, Gray did a lot of research geared to his own unique situation—the outpatient setting, the types of patients. Senior management, it turned out, was very supportive.

Interestingly enough, DR didn’t lead to any staff reductions. In fact, it had the opposite effect. It helped Gray keep personnel and even helped him recruit. “It helps me retain the staff because they realize they’re working with cutting edge,” he says. “Today, it’s hard to keep staff or even to get them in the door. Right now, I am 99% staffed in general radiology, which is a rarity. And we had zero turnover last year, which is also a rarity.”

St. Clare’s Hospital in Denville, N.J., had a completely different situation. The facility deployed DR at the same time it was deploying PACS. It was part of a large-scale, three-year digital conversion project currently at its midpoint.

Like Gray, Jeffrey Wexler, MD, chairman of St. Clare’s department of radiology, found that the high start-up costs were made up by the longer-term savings. “The immediate savings is in film costs, one of the larger costs for a radiology department,” he says. “That has precipitously dropped, and ultimately we will be filmless.”

“It is obviously a lot cheaper to look at all of these images on the workstation,” comments Lawrence Yu, MD, staff radiologist and chairman of the hospital’s endovascular laboratory. “It is also more efficient because interpreting the image can be done much faster.”

For them, the cost justification was a bit harder, but they were able to make their case. “Obviously, this type of arrangement is costly, so we had to show the administration all of the benefits, particularly the long-term benefits,” recalls Wexler. “Once this was accomplished, they were very agreeable.”

Wexler underscores the importance of a well-thought-out strategic plan, especially as it relates to the economics: “The worst thing that you can do is to have to go back to the well again—that is, you come up with a cost of the project and then you realize you need more, and then you have to go back to the administration and ask for more money. Administrations don’t like that.”

He adds that product research is essential to successful implementation. “You have to look at the different players in the field and the different systems and weigh which ones are best suited to your institution,” he says.

Company Offerings
Denville opted for the GE product, while the Children’s Hospital went with Swissray International, Inc. Swissray offers a fixed unit, which Gray found especially suitable to his facility’s purposes, as it serves many children—and children tend to move around a lot. “A fixed unit makes things go a lot quicker for us,” he says. “We don’t have to worry about tube alignment, things like that. It is always fixed, always centered.”

Swissray, based in Elizabeth, N.J., with offices in Europe, established a reputation for offering high-quality DR systems at affordable costs. Its main product is the ddRModulaire system, which features its patented high-speed digital optical design detector technology. The system was designed for high-throughput environments such as Children’s Hospital. It also features a C-arm configuration for maximum positioning flexibility. The digital optical design detector captures a new exposure every two seconds. A diagnostic image is displayed after only five seconds. Garcia praises ddRModulaire as one of the most flexible and competitively priced complete DR solutions on the market. Swissray also offers the ddRCombi and ddRMulti-System. Both handle chest and general radiographic procedures.

Swissray champions the charge-coupled device (CCD)-based detectors. GE, St. Clare’s choice of vendor, offers the amorphous silicon flat-panel detectors. This reflects a division among manufacturers. Some argue the benefits of amorphous silicon over CCD technology. But it is believed among industry observers that the former will eventually prevail. “Most people believe the amorphous silicon flat-panel technology will become the standard,” says Garcia. “Right now, it’s a cost issue because CCD systems are far less expensive. But in five to seven years, when the prices come down and people decide to replace or upgrade, they probably won’t have a problem going with what is considered to be a more advanced technology, which is the amorphous silicon.”

At the heart of GE’s amorphous silicon-based systems is its Revolution detector. “The detector and our ability to do advanced image processing, as well as advanced application, defines our DR products,” says Maloberti.

Also, according to Maloberti, GE products boast the highest detective quantum efficiency (DQE) in the market. Essentially, DQE is a measure of the combined effect of detector noise and contrast performance, and it reflects the ability of the GE system to detect low-contrast objects at lowest dose possible. The measure is recognized as the most accurate gauge of image quality.

GE’s flagship products are its Revolution XQ/i and Revolution XQ/d. The former is a chest system but can be used for other studies as well. “It comes as a tube stand and wall stand system and is for the chest or any exam that requires the patient to stand up,” Maloberti says.

The XR/d systems are general radiography rooms available with one or two detectors. The one-detector room features a vertical wall stand. The two-detector rooms feature an elevating table and vertical wall stand. Both include acquisition workstation, overhead tube suspension, and DICOM and networking capabilities. Also, both can be installed with CAD (computer-aided detection), software that gives a radiologist a second opinion, and both are also available with dual-energy subtraction. This allows two images to be taken less than 150 milliseconds apart, which provides two images—one that reveals bones and one that doesn’t. “With both images, you can see some specific structure that could be hidden by the bone or hidden by a substructure,” says Maloberti.

Expanding Applications
Maloberti says GE’s approach has been to master the basics of DR, providing the best image quality, low dose, and better diagnostic value. Having done that, the company is now developing advanced applications, such as dual-energy subtractions, which provide individual processing for attenuation characteristics of bone and soft tissue. This could eliminate overlapping structures from images and provide better images of specific areas of interest.

Another market player, Philips Medical Systems, has been in the DR market right from the beginning. Its Thoravision system was one of the first dedicated chest units. Today, its star product is the DigitalDiagnost, a DICOM-compatible general radiography system with an integrated flat-plate digital detector and optimized digital image processing. The detector is a highly sensitive piece of technology that generates superior images with minimum dose levels.

Earlier this year, Philips introduced a multipurpose single detector solution that is part of its DigitalDiagnost line. It features a flexible detector carrier mounted on a moveable column that works in combination with a single-sided suspended table or a single-sided moveable trolley.

Portable Options
Canon Medical Systems, based in Irvine, Calif., now offers the CXDI-50G, a portable DR system designed for diverse applications, including trauma and bedside exams. “Traditionally, portable radiography has not been able to enjoy the advantages of digital radiography,” points out Elaine R. Proseus, MBA, RT(R), assistant sales manager .

The lightweight, portable detector, Proseus informs, is used in conjunction with a mobile radiography unit for bedside digital radiograms—eg, patients confined to hospital beds, in intensive care units, or in quarantine.

Canon was first on the market with portable radiology with its CXDI-31, a compact and lightweight system useful for trauma, neonatal, and orthopedic imaging, as well as other applications difficult to set with fixed devices. The newer 50G system is a portable version of the CXDI-40G, a system designed for all general radiographic applications that can be installed in a table or used with an upright or universal stand. Its 17- X 17-inch sensor can capture x-ray images from almost any position or angle.

Canon also offers the CXDI-40C, a highly sensitive system with a high DQE designed for most general radiographic applications.

Canon, Proseus says, also provides upgrades to existing radiography rooms, regardless of their type. “That is where we have excelled,” she says. “Facilities aren’t forced to remove existing equipment and completely replace it with digital. The price tag is very attractive. That’s how we got into the market.”

Looking Ahead
A number of factors are making DR an attractive purchase. The most significant include the increasing implementation of PACS and price reductions that accompany increased production.

Where early adoption was once confined to the largest hospitals and centers, most of the market activity has shifted down to the 200- to 300-bed community hospitals and imaging centers. The increasing acceptance makes it seem more inevitable that DR will eventually supplant CR and certainly conventional radiography.

Increased adoption in this market segment should create a growing awareness of the benefits of DR—increased productivity, reduced costs, and better diagnostic value—and that, in turn, should quicken pace toward digitalization and filmless environments.

— Dan Harvey is a contributing editor for Radiology Today.

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