When introduced in the mid-1990s, digital radiography (DR) generated the unbridled enthusiasm and bold predictions that typically accompany a new technological advancement. Here was a cutting-edge alternative that would quickly replace both conventional and computed radiography (CR). The initial optimism gave way to a tentative embrace. Real-world considerations hindered widespread adoption, and deployment has moved at a slow and cautious pace.

The steep price tag proved a big barrier. At first, the DR market was restricted to the largest institutions that could afford the expensive technology. But, in the past 2 years, the market has started to expand. “In the early years, you only saw it in teaching hospitals and large medical centers, but most of the buying or planning is now taking place in the 200- to 300-beds hospitals,” indicates Antonio Garcia, a senior industry research analyst with Frost & Sullivan (San Antonio), an international growth consulting organization.

Kevin Hobert, manager of digital capture and clinical applications and VP of Kodak’s Health Imaging Group (Rochester, NY), concurs. His company has taken on more midsize accounts. “In the last year or two, we’ve seen a lot of mainstream hospitals, regional healthcare systems, and more imaging centers [make the transition],” he reveals.

The increasing conversion to PACS environments has made DR appear more attractive. Also, more potential customers are aware of the economic and operational advantages it provides. Because DR systems are so efficient, costs per exam decrease while operational efficiencies and productivity increase. Costs associated with film and processing are eliminated. Other benefits include reduced patient exposure and lower radiation dosage (most DR systems use about half the radiation dose of conventional X-ray); increased patient satisfaction (because exam times shorten when images can be viewed immediately and then managed and transmitted easily, patients are handled more efficiently); and better image quality. Also, shorter exam times can generate increased revenues.

Further, as DR technology has improved, the eye-popping price tags are starting to decrease. Still, the initial start-up costs remain substantial, and for that reason alone, a DR purchase must be carefully considered. Every facility is unique. Deployment involves a complex set of questions, and sites must carefully consider both present and future costs and needs to determine if it is appropriate for their own circumstances. Some sites might prefer to get their feet wet with CR before advancing to flat-panel DR systems, while others will jump right in. Still others might deploy both CR and DR. Regardless, a number of considerations must be taken into account before converting to either digital system. Here, experts offer advice to facilities embarking on the conversion.

Appropriate Infrastructure
Next to cost, perhaps, the biggest consideration is environment and infrastructure. DR works best in a facility that has already converted to digital or is in the conversion process. Without the appropriate infrastructure, users won’t enjoy all of the benefits, particularly the productivity and cost efficiency.

Garcia thinks that some type of image management system—PACS, or at least a mini-PACS—is necessary to realize the full capabilities of DR. Otherwise, the investment would be counterproductive. “You’ll have to print images on a laser printer and laser film, and that would incur extra costs above and beyond what it would have cost to just do it as an analog study,” he points out.

Renaud Meloberti, manager of global radiology business for GE Healthcare (Waukesha, Wis), agrees: “DR and PACS go hand in hand. PACS is absolutely necessary to reap all of the benefits.”

As Meloberti’s comment implies, it’s still possible to implement DR without PACS and derive some of the benefits. In fact, some sites have purchased DR without PACS and do realize some increased productivity and diagnostic value. However, the DR purchase should be part of a larger plan—a progressive implementation—where PACS will soon follow. “At most of the sites, whether they have CR or DR, an overall strategy is in place to implement PACS,” Hobert says.

Deborah Imling, marketing manager of the digital imaging systems business group for Philips Medical Systems (Bothell, Wash), says, “You don’t need to have PACS to go DR, but why do it? One of its major benefits is no more film, but if you haven’t reduced your film costs [via PACS], then you haven’t gained anything from a financial standpoint.”

Quick Questions If your facility is thinking of converting to digital, ask these questions to help prepare: Are you bringing the technology into an environment equipped with supportive infrastructure (eg, image management systems, such as PACS or mini-PACS)? If not, is the DR purchase part of an overall implementation that will include PACS? Do you have sufficient patient volume to realize throughput benefits and justify the cost? Are you prepared to face the prospect of staff reductions that might result from increased productivity? Have you drawn up a workflow re-engineering strategy? How do your referring physicians feel about DR technology? Will they be comfortable with the transition? Have you researched the vendors and products to determine which are most appropriate to your site’s unique needs? Would CR be the more appropriate choice for your site’s needs? Have you developed the complex financial calculations that will help justify the DR purchase to administration? Will estimated cost savings justify the large initial investment? What are your specific reasons for wanting to deploy DR: Improved operational efficiencies? Lower dose? Decreased workflow? Reduced costs? Is DR the answer to these questions? —DH

Volume Levels
Patient volume is another crucial consideration. Facilities need to assess their volume and determine if it justifies the costs. “You really need to understand—right down to the last decimal point—what your operating costs are, what your patient flows are, and how those will change over the next 10 years,” asserts Ralph Schaetzing, PhD, distinguished scientist with the Agfa Corp (Ridgefield Park, NJ), a company that offers both CR and DR solutions.

To illustrate his point, Schaetzing relates the example of one department’s purchase of a flat-panel DR chest system. The department manager found that DR did speed up everything. However, in this particular clinical environment, there just weren’t enough patients to benefit from this throughout the improvement. “For many institutions, this sexy new technology might not be the right choice for their particular situation,” he says.

Garcia recommends that sites look at current and future costs to determine if the savings over the long run will help ameliorate the high start-up investment. “You don’t get the savings from DR itself,” he explains. “You get savings from the workflow re-engineering and from going filmless.”

As such, a DR purchase will entail a change in the way a department operates. “If you try to run the department the way you ran it when it was film-based, then you’re not going to save a lot of money,” Garcia says. “You will, in fact, spend more.”

This concept, he adds, leads into a sensitive subject area. Workflow re-engineering results in productivity benefits that can lead to personnel reduction, and a facility needs to be aware of the possibility. “That’s a big area where people are going to save money, but it’s not a very popular area,” he comments. “Some tough questions are involved with going DR, and that’s one of the toughest.”

Fortunately, staff reduction isn’t always a direct result of deployment. In fact, quite the opposite can be true. Hobert says that DR can serve as an effective recruitment tool. “Access to new technology has been shown to improve radiologist satisfaction, which helps with retention or recruiting,” he says.

Such was the case at Children’s Memorial Hospital (Chicago). The facility’s experience with DR implementation makes for an instructive “success story.” When considering DR deployment, the site was guided by its own unique set of needs, and it followed a logical implementation path. “We support some busy orthopedic clinics, and the DR solution seemed tailor-made for that,” says Ken Gray, RT(R), CTCV, director of imaging at the hospital.

The facility brought DR into a PACS environment, while the hospital’s main campus used CR products. Looking for a technology that would interface well with PACS, Gray decided to go with DR. Children’s Memorial has enjoyed the benefits for over a year now. Also, DR didn’t lead to any staff reductions; rather, it helped Gray keep personnel and even helped him recruit. “It helps me retain the staff,” he says, “because they realize they’re working with cutting-edge technology.”

Vendor Choice
Jeffrey Wexler, MD, is chairman of the department of radiology at St Clare’s Hospital (Denville, NJ), where DR was implemented at the same time that PACS was deployed. He recommends that comprehensive product research precede implementation. “You have to look at the different players in the field and the different systems and then weigh which ones are best suited to your institution,” he advises.

Not only must the most appropriate system be selected, it’s important to consider the vendor as well. Philips’ Imling recommends that potential buyers select a vendor that appears committed to the technology. She recalls that when DR first came out, some companies tried to get into the game by offering lower-end systems at lower prices. Customers who went that route found that the products didn’t meet their demands for image quality and radiation dose levels. Eventually, and for obvious reasons, these companies started going out of business, and customers were left without service.

“The potential vendor should be one that looks like it will be in the market for a long time,” she says. “And if they do offer low-end or mid-range systems, make sure the product meets your standards.”

CR vs DR
Contrary to early predictions, DR hasn’t replaced CR, and it won’t for some time. The market for CR remains strong for several reasons. For one thing, many see CR as a good stepping-stone into DR. Others see CR as just as good as DR, when all of the advantages and disadvantages of both are weighed. Therefore, some vendors recommend that sites consider CR over DR. Garcia, who feels that both technologies will co-exist for about another 10 years, reveals that a handful of major vendors who facilitate the transition from film-based to digital environments even throw in CR as part of the PACS contract.

The choice between DR and CR, Kodak’s Hobert says, comes down to clinical use and patient volume. Agfa’s Schaetzing breaks it down even further, into four criteria classes: technical, clinical, operational, and economic. As far as technical criteria, dose is the major issue, and DR has a clear advantage in terms of dose efficiency, he says. In the clinical area, image quality is the main issue, and Schaetzing feels there is no clinical significance in the difference between CR and DR. As he points out, studies have revealed that DR flat-panel technology provides the same diagnostic accuracy as film or CR. From a clinical standpoint, it is hard to argue for one over the other.

“When comparing the two, it is interesting to look at the evolution of image quality over the last 100 years or so,” he says. “There have been lots of changes. On the other hand, the diagnostic accuracy of radiologists—essentially, their error rates—haven’t changed at all. So either image quality is pretty much irrelevant for diagnosis, at least at today’s levels, or manufacturers haven’t been able to make a significant enough change in image quality to move digital diagnostic accuracy, if you will.”

Garcia of Frost & Sullivan agrees that facilities don’t buy DR for imaging quality. The technological area is more important, as is the operational criteria. In that area, Schaetzing says that flat-panel DR has the clear advantage because more patients can be sent through a flat-panel DR system than a CR system in the same amount of time.

As far as economics, CR is way out in front. The high start-up cost is the biggest factor that has hindered the broader adoption of DR. “If you look at the acquisition costs plus room modifications—the new X-ray generator, new tubes—you’re talking very big money to get into that game,” Schaetzing says.

In addition, DR is expensive to service. As Schaetzing points out, a facility that experiences DR detector failure will have to put out anywhere between $30,000 and $50,000 for a new one. On the other hand, a CR detector failure would cost only about $1,000. “So some very strong economic reasons are why flat-panel DR is not booming,” he concludes.

And that makes it a hard sell to decision-makers.

Convincing the Administration
Even with prices coming down, DR systems can still cost twice that of conventional radiography equipment. On first glance, it seems more attractive to put out $60,000 to $90,000 for a bucky room as opposed to $500,000 for a DR system. Therefore, cost justification will involve a great deal of research and analysis followed by persistent campaigning.

Any good campaign includes economic projections and complex cost-savings calculations to help state the case. When St Clare’s Hospital was considering its DR purchase, Wexler persuaded the administration by spelling out in detail all of the benefits, particularly the long-term benefits. “Once this was accomplished, they were very agreeable,” he recalls.

He cautions that a plan needs to be meticulous, well prepared, and well presented. Most importantly, the cost estimates must be correct. The worst thing you can do, he says, is come up with a project cost and later realize you need more money. “Administrations don’t like that,” he says.

Some departments sell DR by presenting it as a good marketing tool that will help increase revenues by providing a higher level of service, efficiency, and turnaround time. “Patients like it better, so you can market it to patients, and that attracts referrals,” Hobert says.

When considering revenues, it’s also important to consider the referring physicians as well as the patients. Wexler says it’s important to determine how the referring physicians regard the new system and handle the transition.

Vendor/Customer Consultation
DR deployment is a significant undertaking that doesn’t just entail copious research. It is also logistically complex (involving equipment installation, room consolidations, workflow re-engineering, and the like), and it requires cooperative effort among administrators, staff, and vendors. On the surface, that might seem daunting. Fortunately, the major vendors offer consultation as part of their services. These consultants work closely with the customers, addressing the major issues and concerns.

Imling says that Phillips’ field representatives assess each facility as a unique entity and determine specific needs and circumstances. “They’ll determine why they want to go digital in the first place,” she says. “What are the main reasons? Do they want to decrease their workflow? Are they trying to cut costs?”

The major issues addressed involve how much money exists in the budget and the size of the patient load. “That will determine if they are ready to go into CR first or to DR,” she says. “If you really don’t have the patient load, then it doesn’t make sense to go to DR for that kind of workflow.”

Phillips representatives help facility administrators examine elements of operations down to fine detail: quantity of films per study that are performed during the course of a year, staff costs and overtime pay, film and storage costs, etc. “We do all of these things not only for image management but also to determine what will be eliminated and, from there, determine if it makes sense for them to go CR or DR,” Imling says.

Kodak provides the same preimplementation analysis. “Depending on the different circumstances of the site, we can try to help administrators modify the benefits [of the technology], take them to different sites to show them examples of the benefits, and put together an economic analysis,” Hobert explains.

The final decision, he indicates, is based on both economics and patient care. “We try to help administrators decide what is best for their specific set of circumstances and then implement the appropriate plan,” he says.

Clearly, a number of factors make DR an attractive purchase. The most significant include the increasing implementation of PACS and price reductions that accompany increased production. Market activity was once confined to the largest hospitals and medical centers. Now, more and more mainstream hospitals and imaging centers are deploying DR.

However, the investment must be carefully considered. Prospective buyers need to carefully research the purchase, and appropriate choices need to be made regarding systems and vendors—based on a site’s own set of current and future needs and costs, existing infrastructure, and patient volume.

Dan Harvey is a contributing writer for Medical Imaging.