This report originally appeared in the February 2011 issue of DOTmed Business News

It wasn’t that long ago when X-ray departments at hospitals and medical imaging facilities were contemplating whether to transition from their analog systems to computed radiography, direct digital radiography or a combination of both.

Now it looks as though DR will be the answer for more hospitals than previously anticipated thanks to lower price points over the last year.

Some, such as Shawl Lobree, VP of marketing for Philips Healthcare’s diagnostic X-ray business, believe CR has finally run out of road. “For the medium and large hospitals in the United States, I think CR purchases are really going to plummet,” he says. “CR sales have been shrinking and we are seeing that trend. The CR purchases we are seeing now are in outpatient centers or ICUs as hospitals are going away from big CR purchases.”

Others, like Eileen Heizyk, worldwide marketing manager for Carestream Health, believe CR still has some life to it but acknowledge DR is edging it out. “Both are still growing and there are still applications all over the world where we need to help our customers move into the digital world,” she says. “DR is experiencing double-digit growth world wide and though CR is growing at a slower rate than it has in the last five to 10 years, it is still viable.”

When DR rooms first hit the market, typical prices were in the neighborhood of half a million dollars. Today, a good DR room could be had for about half that amount.
“DR is starting to approach the pricing of CR with all the competition,” says Rob Fabrizio, senior product manager of modality solutions with Fujifilm Medical Systems U.S.A. Inc.

Portable DR and wireless
The market’s interest in portable DR has been noted by many manufacturers and some of the market is growing. For years, GE Healthcare had the lion’s share of the DR mobile market with its AMX family of products. In 2003, Canon USA, Inc. became the first on the market with a wireless DR portable. That was followed in 2005 by GE upgrading its AMX products with a wireless detector. This year, Agfa HealthCare will release its portable DR, the DX-D 100.

“Today’s buzz is all about wireless detectors and that’s really where the industry is going,” says Boris Geyzer, senior specialist of product sales for Canon. “The next great thing is going to be with DR mobile."

An explosion in wireless detectors over the last year has resulted in a flexible, easy transition to DR from existing analog or CR. Even for those hospitals that already employ a DR room, wireless provides the perfect complement to allow a portable DR detector in a cassette size that can be used for cross-table work and wheelchair exams.




Wireless is important for radiography departments, as it speeds the work process allowing for more imaging and it also pulls the plug on a former hazard. “The simple innovation of getting rid of the cable is huge. Eliminating the tether was so big because it’s almost impossible to keep it clean in an operating room environment,” Philips’ Lobree says. “Patient positioning freedom is another huge benefit because you don’t need to struggle with getting the cable around or under the table.”

Lobree expects to see a big shift with people buying wireless detectors with their DR rooms and their portables.

Fujifilm will release its new wireless DR, the FDR D-EVO, sometime in the first few months of this year. “Wireless systems are important in DR as it puts the electronics closer to the focus of the captured X-ray photons that are absorbed by the layers inside, so it creates stronger, sharper images,” Fabrizio says. “With our design, we are able to achieve a dose reduction from our original CR of as much as 30 percent.”

DR durability
When DR was first introduced, some in the industry were slow to adopt the technology due to questions about its durability. While still not as durable as CR, major strides have been made to address the market’s concerns.

“It was an issue in the past but durability is getting better and better,” Lobree says. “Rarely do you see detector failures anymore. Software has gotten much more stable, the image processing has gotten easier to use and converting from CR to DR has gotten a lot easier and a lot more reliable.”

Still, CR can stand a lot more of a beating from the normal use of a portable system and even if one were to drop and break the cassette, it’s not as expensive to replace.

“From our perspective, the biggest concern we’ve heard from customers is about the DR plate fragility and cost to replace,” says Nicholas Hersman, associate product manager of Medrad Inc. “Service level agreements on DR systems will cover the DR plate, but will not cover misuse and abuse. Our customers have indicated that the primary means of failure on the plates is due to dropping them, thereby making the contract null and void.”

Fujifilm is the lone OEM offering insurance policies for dropping the detectors. “When it comes to DR in a portable type of device, customers are going to need to be a little more careful with it,” Fabrizio says. “They are designed to be a little more rugged and not break easily, but they are a lot more fragile than a CR cassette. In some environments, CR is going to be a better choice.”




Steve Eisner, marketing manager for Konica Minolta, says durability is only half the equation. “The replacement cost upon failure is the real issue,” he says. “DR detector failure is a significant issue. The financial risk is much greater than in CR even if failure rates were the same or reduced. The concern is that portable DR detectors will be more prone to damage and theft.”




Scintillator choice
There are two major detector designs using scintillator technology: gadolinium oxysulfide (GOS) and cesium iodide. “This has been a huge topic in DR lately and we are seeing more companies shift into cesium iodide or offering both,” Philips’ Lobree says.

GOS is the original type of scintillator used for years in portable detectors and is more durable, lighter and less expensive.

“That makes it much better with portable detectors because you just know it’s going to get dropped at some time and you want it to be as light as possible,” Fujifilm’s Fabrizio says. “Cesium iodide creates a higher image resolution. However, it’s more expensive, heavier and contains crystals, making it much more fragile. Those are things that work against it in a portable.”

For applications like high-resolution lung imaging and soft tissue details, cesium iodide’s benefits outweigh its costs for some clinicians. The same holds for pediatric imaging.

“For someone at an orthopedic clinic, they probably don’t need to spend the extra money for cesium iodide,” Lobree says. “For someone doing everything including pediatrics and lots of high-res chest imaging, everyone recognizes that cesium iodide gives advantages in image quality and dose.”

Dose issues
With some negative press regarding high-dose exposure in the past year, doctors are feeling the pressure to provide the best care with the lowest dose possible. That anxiety is being passed to the OEMs that are being tasked with providing a solution.

“There’s a lot of talk about dose reduction,” says Greg Cefalo, U.S. business imaging manager for Agfa HealthCare. “We take it seriously. You don’t want to take the dose down and lose clinical information. You want to be sure you are getting the information a physician needs to make the diagnoses.”

According to Aaron Ybarra, X-ray product manager for Toshiba America Medical Systems, customers have been asking more about dose in the past few months.

“What’s coming down the road is DICOM dose structured reporting, as a lot of customers are concerned with this and radiation,” he says. “We started working on DICOM reporting last year and we are hopefully going to see that become part of our product in June of this year.”

“Dose is the big newsworthy topic that is out there and it will be newsworthy for a while,” says Kris Kessler, creative marketing manager for Canon. “As there is a greater emphasis, you will see more solutions.”

Canon implemented dose decreases on its new wireless detector, the Canon CXDI-70C Wireless Digital Radiology System, yet also increased the resolution by 50 percent.

FDA action
The U.S. Food and Drug Administration’s recent reclassification of some digital mammography devices to Class II reduces the barrier of entry for some companies that have mammography plans in place. It also reduces an obstacle for brand-new entrants, but the technical requirements are still significant.

“The initial impact is several new products have been approved by the FDA and we’re expecting it to be a much easier process in the long run,” Fujifilm’s Fabrizio says. “Mammo was classified as Class III, requiring pre-market clinical trials. Now it’s downgraded to what is basically the same as all of our X-ray products. It will bring more competition and be a benefit for the customers as it will result in better products and faster release of new products.”

This will enable Fujifilm to release its Aspire HD DR product two years ahead of time.

Carestream, which had already been selling its mammography units all over the world, is excited about making its products available to its U.S. customers soon. “Now that we have approval from the FDA, which we actually received under the strict guidelines before they loosened the rules, we will be selling more of our CR systems into the mammography settings,” Heizyk says.

For Agfa, the new classification will help the company’s release of its latest offering for the U.S. breast imaging market — the IMPAX, which offers relevant prior exams automatically pre-fetched from the archive management system and sent to the diagnostic review station.

“There were a lot of people who were frustrated with the FDA for taking so long to downgrade that category,” Cefalo says. “I think they were feeling the pressure because the technology was available throughout the rest of the world. The bureaucracy was in the way of giving American women access to technology widely used and widely valued.”

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

Domestic
Joseph Shafe, Assured Imaging, AZ
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
Klaus Kraemer, Multi Imaging Systems, Inc., CA
Kenn Matayor, Jaken Medical Inc., CA
DOTmed Certified
Aaron Ybarra, Toshiba America Medical Systems, CA
Rob Fabrizio, Fujifilm Medical Systems USA, Inc., CT
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DM 100
Rodolfo Gutierrez, EMI America Miami Medical Equipment, FL
DOTmed Certified
Kris Kessler, Canon USA, Virtual Imaging , FL
Ed Ruth, Managed Medical Imaging, FL
Robert Serros Jr., Amber Diagnostics,FL
DM 100
Larry Sprague, Imaging Resources, GA
Ted Turano, X-Stream Medical Inc., IA
DOTmed Certified
D. Fosco, Redfish Medical Inc., IL
DOTmed Certified
DM 100
Bob Gaw, Physicians Resource Network, Inc., MA
DOTmed Certified
DM 100
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed Certified
Ronny Bachrach, Viztek, NC
Harley Warren, Medical Equipment Expense Solutions, NC
Steve Eisner, Konica Minolta, NJ
J. ORourke, LJ Technologies, NJ
DM 100
Richard Owen, Medlink Imaging, NJ
Joseph Jenkins, International Imaging Ltd., NV
Sal Aidone, Deccaid Services Inc., NY
DOTmed Certified
Omar Barlas, Peridot Technologies, NY
Hugh Cotty, JC Medical Equip. Co., Inc, NY
Eileen Heizyk, Carestream Health, Inc., NY
Brian McKeon, TI-BA Enterprises, NY
Robert Muzzio, GXC Imaging, NY
Jeff Root, Merry X-Ray Corporation, OK
Nicholas Hersman, Medrad, Inc., PA
Michael Lies, Medical Advantages Inc., PA
DOTmed Certified
Paul McCabe, Imaging Services, Inc., PA
David Hurlock, Varian Medical Systems, SC
Jim Whittaker, Mid Atlantic Telerad, VA
Rex Harmon, IMIX Americas Inc., WA

International
Thomas Gibson, TP Global Medical Equipment, Mexico
DOTmed Certified
Imad Muati, IMC, Syria

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