Film is losing favor, but the role of successor is still up for grabs.

Hospitals and imaging centers often rely on CR technology like Kodak's Directview CR 950 System.

For more than 100 years, film was the mainstay of radiography imaging. Supported by bulky light boxes and cumbersome labs with chemicals, it has been—and still is—a proven, reliable source. Over the last 15 years, film has been challenged by computed radiography (CR).

With industry estimates of 40% to 70% of all radiology imaging workload being performed through projection radiography, CR has established itself as a serious player in the total volume of images being acquired, interpreted, and distributed for clinical purposes.

But like any technology, CR's reign may be far shorter than that of classic film. Growing increasingly popular is direct radiography (DR). When it's running properly, one DR room can process as many patients as three conventional film rooms.

Both CR and DR are expensive. The cost of CR with cassettes is roughly $100,000 to $250,000, depending on throughput capacity, and approximately $15,000 a year in servicing. DR costs approximately $400,000 per room and $48,000 in servicing annually. But it's clear that digital has taken hold.

Time to Upgrade

Frana Evans, director of radiology at the Springfield Clinic in Springfield, Ill, found herself debating all those concerns when she made the decision to add both CR and DR to a new facility. Springfield Clinics is a physician-owned operation consisting of 70 physicians at seven different sites. When the decision was made to open a new facility in 2006, Evans decided it was time to upgrade to digital. The new facility now has a digital platform consisting of three DR and one CR machines. All are made by Kodak, now Carestream.

The first hurdle Evans faced was convincing the physicians. Because of the cost they were leery. They were also used to analog and felt it served their needs sufficiently. "If people haven't seen DR," she said, "they definitely need to make a site visit, especially if the place has both DR and CR." Which is exactly what she did. Not only did she and her team examine systems from four vendors, they also flew to several out-of-state facilities for site visits. She reported back to her physicians with what she saw in terms of speed and efficiency, and they finally came around.

The decision to install both CR and DR was made based on need. "We do a large number of full leg length and full spine studies," said Evans. "There's no efficient DR that can do that kind of imaging in one exposure. You're subject to multiple exposures with a moving apparatus." CR fit the bill. Because of the multiple cassettes, it's capable of multiple exposures, which are then stitched together. "The finished product is flexible," said Evans, "because it gives you one long image, but you also have access to the individual images."

Despite the advantages of DR, which Evans acknowledges are primarily time efficiency and image quality, the new clinic uses CR for a wide variety of purposes. Examples include any kind of weight-bearing images, images of the feet, images of the spine related to scoliosis, and images of patients with limited movements.

Rolling Out Digital

Springfield's newest clinic is the only one in the system that currently uses any kind of digital. But more are on the way. "We'll be rolling out digital over the years," said Evans. "Where I can go strictly digital, I will. But some will have to have CR as well, especially the smaller units with smaller volume."

The physicians at Springfield are more than convinced by now. They are in fact eager to install the digital equipment at their other sites so they won't have to courier film between them. "We went from a department with four rooms to one with two rooms, but increased volume," Evans said. "Our orthopedic surgeon has probably the highest volume in the building. At first he wasn't a fan. But then he realized he was looking at images on the monitor before I could walk the patient back from the exam room."

The flexibility of Canon's CXDI-50G Portable DR Sensor is demonstrated by positioning the plate to do a sunrise knee technique; and it offers the ability to retrofit existing x-ray equipment.

Lori Wainio is the assistant director of diagnostic imaging for Kaiser Permanente in Northern California. Her decision to go with a DR system by Canon had to do not only with increased productivity and greater speed, but also with the health of her technicians. "We've seen a mitigation of ergonomics issues with DR that are not mitigated with CR," said Wainio. Every image made with CR requires a technician to handle cassettes five times. In a busy clinic, each technician is handling 60 to 80 patients per day. Earlier this year, two technicians suffered repetitive motion injuries. "With DR that is now mitigated," she said.

Given the speed of the DR system she purchased, and the fact that the Canon model doesn't require retrofitting the exam room, Wainio isn't sure there's a future for CR. "Both have their places," she said, "but in the future, I can see an industry that will be all DR. It makes sense from the speed perspective and the ergonomic perspective." She is especially convinced that "the future is DR" because of the flexibility of the tethered plate. "Before the tethered plate, CR was better," said Wainio, "but with the tethered plate, there isn't anything that CR can do that DR can't do." What will she do with her CR equipment as we approach an all-DR world? "We donate used equipment to third world countries. Every facility is different, but that's what we do."

A major factor contributing to her ability to purchase the DR equipment was the fact that the Canon model

didn't require retrofitting the exam room. "The funding we received for this was predicated on the fact that no major construction to the room was required. We would not have received the funding otherwise. That's what made it affordable. And between installation and application, the room was down only six and a half days."

X-ray Is Fun Again

Wainio's technicians are enthusiastic as well. Four of them have done the training for DR, and all four picked it up very easily. One even commented that x-ray was fun again. For Wainio, the upside of a very low learning curve is that the techs can give more focus to their patients.

In terms of the future, Wainio can't imagine that imaging will get any faster than it is now with DR, but she's sure that things can only get better than they are. She has some thoughts on what the R&D guys in the industry should be focusing on, however. "I'd like to see them working on ways to decrease x-ray exposure doses. That would definitely make the techs' jobs easier. I would say that's the next thing to work on."

Rick Perez is the administrative director at Winthrop University Medical Center in Mineola, NY. Perez supervises a department that uses Carestream digital imaging, and, as would be expected in a university medical center, his department uses both CR and DR. As with the others, there's no dispute in his mind that DR provides greater speed and efficiency due to instantaneous images while CR requires a processing component. However, because of its portability, he does see a very real place for CR in a hospital setting, particularly in rooms such as the OR, ER, and the ICU. But the flexibility of the DR, due to the cable connecting the controller to the receptor, is limited. "We're beginning to see DR come into play, though we're all a little shell-shocked at the sticker price," said Perez, "but you're always attached to the cable." He looks forward to the technology becoming wireless and freeing up the platform to be more flexible and portable.

Careful Planning

Perez also said that planning carefully for the transition to digital is ultraimportant and that there are options depending on the scope of your project, space, and budget. "Depending on procedure mix, DR can improve productivity by 20% to 30%, but you typically have to replace the diagnostic room, which is expensive. CR can be deployed to replace existing processing equipment, which will service many existing diagnostic rooms and portable examinations. It can make the staff 15% more productive."

Particularly for smaller organizations, Perez said the decision of whether to go with DR or CR needs to be carefully considered as part of the overall business plan. "There's a real balance as you look at the ROI," he said. "There's the cost of the device, and there's also labor savings. You have to look at the costs spread out over multiple rooms and staff involved. It will make your capacity that much higher."

He also cautions that in a facility with only one room, the choice to go with DR would not be wise. "My concern is that if you have only one room, and you go with DR and it breaks down, you're out of business." Even larger-scale private centers shouldn't get rid of CR completely, he argues, again because the loss of a room can be tough. "In the hospital," said Perez, "if I lose one, there are always others. I can always get by until it's fixed."

Perez also cautions that once the decision to go digital is made, there will be a need to change processes and behavior in the department, presenting a different set of challenges. "The staff and the radiologists will all need to be trained, and everyone will have to buy into the process, otherwise you won't be successful." He also advises that your process will need to be continuously reviewed and updated and that communication between staff, vendors, and customers must remain open to ensure that the department's goals are met. "Integration of all systems is key to success," he added.

Nikos Valance is a contributing writer for Medical Imaging. For more information, contact .