It’s been nearly 20 years since computed radiography (CR) hit the medical imaging market. CR is a fairly mature technology with an installed base of just over 3,000 units, according to Frost & Sullivan (San Jose, Calif.). A fair share of that growth occurred in recent years as CR technology matured and prices dropped. The CR market should continue to experience robust growth in the near future; market analysts at Frost & Sullivan predict that the installed base of CR units will continue to grow for most of this decade.

Hospitals that have implemented CR are quick to list its benefits — decreased repeat rates, increased throughput and productivity, and better quality images. One of the primary advantages of CR, however, has nothing to do with image quality or productivity. CR has a much more palatable price tag than its higher-priced cousin — digital radiography (DR). In order to spur growth and meet the needs of a broader market, CR vendors are continuing to develop and market new CR alternatives such compact all-in-one units, ultra high-throughput systems, and even mammography units. In fact, the availability of a wider variety of CR alternatives may be the biggest change in the market. Sally Grady, director, imaging center for Florida Hospital Celebration and Kissimmee (Orlando, Fla.) says, “Five years ago when we first bought CR, the vendors had one package.” That one-size-fits-all approach is a relic today. Grady continues, “Now you can piecemeal CR and get a system for the price you want. You can get it with all the bells and whistles or none. It depends on what you need and how much you can spend.”

 Kodak Direct View CR900 system

A short history of CR
Jerome Burstein, M.D. and director of radiology at Lovelace Medical Center (Albuquerque, N.M.), may have been one of the initial CR converts. Burstein was first introduced to CR in 1981 at the Radiological Society of North America (RSNA) meeting. A CR vendor had displayed a series of skull x-rays as if they had been taken in an actual radiology department. Some of the images were overexposed, some were underexposed, and some were good. Also on hand were the same images completed with a CR system. All of those images were good. “I realized this represented a significant change in the way radiographic images were created,” Burstein relates. “You didn’t need to worry about whether an image would be underexposed or overexposed. CR is much more forgiving than analog film.”

 Fujifilm’s SmartCR

Burstein continues, “I always saw CR as the way of the future. But there was always the issue of cost and practicality.” Fast forward a decade or so. CR technology had evolved, and, at the same time, picture archiving and communications systems (PACS) developed. That convergence of technologies enabled Burstein and Lovelace Medical Center to pursue CR. Burstein explains, “CR or DR is a necessary building block for PACS. But DR is still in a state of evolution, and it’s very expensive. We have an installed base of equipment. I’m not going to tear out an existing room [to install DR]. CR is much more practical. It lets you take advantage of your investment in radiology rooms.”

Most practical, budget-minded radiology administrators would agree with Burstein’s assessment. Even in the case of a new facility, which doesn’t have the existing radiology room issue, CR can be the wise choice. When Dakota Clinic Limited and Innovis Health (Fargo, N.D.) opened the doors to its new 77-bed, non-profit facility in 2000, administrators quickly decided not to pursue DR because of its high acquisition cost. Still the hospital was committed to implementing a state-of-the-art, all-digital radiology department. Shawn Worley, director of radiology at Innovis Health, says, “I wanted a digital department and CR units made sense.”

The hospital purchased three Kodak DirectView CR 800 units and one DirectView 900 for its new facility. The CR 800 is a compact system that can be used to service individual rooms. At Innovis Health, the CR 800 is used in an orthopedic room, emergency room and central core area. The CR 900, on the other hand, allows technologists to load eight cassettes at a time and can support multiple exam rooms. Designed for a centralized, high-volume CR environment, the CR 900 services the main radiology department at Innovis Health. Worley explains, “The CR 900 gets used for all our exam rooms in the main radiology department — anything from portables to routine radiographs and fluoroscopy.”

The hospital also purchased four remote operations panels from Kodak. The wall-mounted panels, which are touch-screen devices with computing power that can be hooked up to the CR units, essentially create a mini-network. With the remote operating panels, technologists can enter patient/exam/cassette identification, check image quality and reprocess, if needed, images before they are transmitted — all from the examination room. The bottlenecks that can occur with data entry are eliminated. The panels also let radiologists and physicians view any CR image in the hospital. The end result is enhanced workflow and productivity.

While CR does allow entry into the digital world for a fairly reasonable price, economics isn’t the only factor fueling CR’s growth. After all, there isn’t a product on the market that is wise investment if it doesn’t perform. And CR does perform. Image quality, for example, can be superior to conventional film.

At Lovelace Medical Center, economics, practicality and clinical need combined and spurred administrators to purchase CR. CR did have a relatively attractive price tag, and the center was planning to install PACS and go filmless. But Burstein says, “The first use that I was able to sell CR to administrators and myself was based on clinical ground.” As in every film-based hospital, there was tremendous variability in the quality of Lovelace’s portable chest films. The sickest patients were getting the worst care, says Burstein, because we couldn’t always get good images. So the hospital purchased a CR chest unit from Fujifilm Medical Systems (Stamford, Conn.).

“There’s been a significant improvement in the quality of portable chest studies,” Burstein says. “Now all of our portables look the same. That proved the point for all other CR applications for us.” Lovelace purchased virtually every Fujifilm CR system on the market. The departmental workhorses are several SmartCRs, Fujifilm’s compact CR unit. SmartCR is a fully integrated system with the image readers, workstation, imaging plates and cassettes, and can attain throughput of 56 to 90 plates per hour. Lovelace rounded out its CR portfolio with Fujifilm’s 5501D digital chest unit and SpeedSuite digital x-ray table.

CR vs. DR

Hospitals that want to implement digital essentially have two choices — CR or DR. According to analysts at Frost & Sullivan, a combination of several factors account for CR’s relative growth compared to DR. First, there is minimal PACS infrastructure in place. Second, no surprise here — hospitals prefer lower-priced equipment. A ballpark price estimate could scare off even a spendthrift buyer. One CR system, with a pricetag of $150,000 to $180,000, can service four radiology rooms. The same DR component might sell for a cool million.

 Agfa’s Solo CR

Ted Ciona, senior marketing manager for CR and DR systems for North America, for Agfa Healthcare (Ridgefield Park, N.J.), notes, “DR vendors sell the workflow advantages of DR, but hospitals don’t necessarily have patients lined up out the door.” Without a certain threshold, or surplus, of patients, it is difficult to realize marked workflow improvements.

Grady of Florida Hospital isn’t convinced of the marked throughput differences between CR and DR. “There are studies out there showing that DR is three times faster than CR, but if you set up a CR system appropriately, DR doesn’t beat CR by that much.” Finally, not all end-users have accepted or established a comfort level with DR equipment. DR, however, is expected to enjoy a more robust growth rate toward the middle of the decade after hospitals have built up their PACS infrastructures and DR systems prices have fallen.

Compact systems, distributed workflow

Compact CR systems, such as Fujifilm’s SmartCR and Kodak’s CR 800, are a fairly new addition to the CR market. These systems cannot attain the throughput or capacity of larger central readers, but their price tag is quite a bit lower. A compact system can be used to service a radiology room in a hospital setting. The compact footprint also makes these devices ideal for smaller facilities including imaging centers, remote clinics or mobile radiologists. Kodak’s CR 800 features all of the components needed for image capture, processing, quality assurance and image handling/networking in one unit. It can be placed closer to patients, which allows the caregiver to stay close to the patient. The results newer compact systems can achieve are substantially faster than their older counterparts. Agfa’s Compact Plus, for example, can process 90 plates per hour instead of 70.

One CR company, OREX Computed Radiography (Boston and Nesher, Israel), has based its business strategy on compact CR and the resultant distributed workflow. Hillel Bachrach, president of OREX, says, “Our philosophy is that every radiology room should have CR.” With a centralized CR processor, techs can get bogged down as they run back and forth from exam rooms to the processor and wait for images. A compact CR system, such as OREX’s PcCR 8×12 or PcCR 14×17, may have slower scanning times than a multi-cassette, centralized system. With a compact system, however, the tech can remain in the room through the imaging process. Workflow is enhanced because the system eliminates both the walk from exam room to processor and the lines at the central system.

Compact CR units also can serve as a supplement to DR. Bachrach explains, “When a hospital purchases DR, it creates an imbalance in the radiology department. Physicians will want to send all patients to the room with the new technology.” Typically, this isn’t possible, so to facilitate the move to filmless, it makes sense to purchase economical compact CR systems for radiology rooms not served by DR.

Another space-saving option is a single-plate reader. Florida Hospital Celebration Health added Agfa’s Solo CR system to its surgery area. The device takes up about two square feet and can process one plate at a time. “It’s a nice option for lower-volume areas,” Grady says. “It could be utilized in the ICU or in an area where techs are doing a lot of portables.”

These small, single-plate CR devices make it possible to more efficiently distribute CR workflow. Ciona of Agfa predicts that the distributed CR workflow trend will continue. The compact devices allow the tech to remain in the x-ray room and flip, rotate, analyze and return images. “It’s more efficient not to have everyone standing around at a central location and it allows more redundancy if something goes wrong. I don’t know if people will want to centralize again.”

The CR advantage(s)

Like other CR institutions, Lovelace Medical Center has realized many of the benefits of CR — both throughput and image quality have improved. John Ervin, M.D., director of radiology at Lovelace Medical Center, acknowledges that many of CR’s cost benefits are anecdotal. “Accountant types could develop a formula for conserving time and maximizing efficiency and come up with an hourly amount saved. I can tell you that we have seen a 50 percent reduction in repeat rates for technique issues, and productivity has increased as far as the amount of patients pushed through our rooms because there’s no going back and forth to the darkroom.”

The hospital’s lost film problem has been solved as images can be located on disk, and care has been improved because radiologists complete more timely reports.

Worley of Innovis Health adds to the list of CR benefits. Its CR systems track technologist’s repeat rates and exposure habits, and the system tells techs and radiologists when it isn’t working. CR images can be redirected to other printers, the archive or a second CR unit via the network. With the hospital’s Web server, physicians can view exams in their offices or at home. These factors translate into a hostof patient-care benefits. Worley summarizes, “Our patients get better x-rays, higher quality care and lower radiation doses overall.” Grady adds that CR has made techs better patient caregivers because they spend less time on clerical duties.”

Burstein lists a few secondary advantages. “You’re getting away from the dark-room. There are no chemical abatement issues. We’ll eventually stop buying and printing film and put the processor away in a storage room.”

On the CR horizon

Although the CR market is fairly mature, it is (and will, according to most experts) continue to experience fairly robust growth. Kodak plans to offer broad solutions so that customers can choose the CR products that best suit their needs. Richard Jebo, general manager for CR products and vice president of Health Imaging, for Eastman Kodak Co. (Rochester, N.Y.), confirms that there are a lot of CR products in the pipeline at Kodak. Product development is focused on adding features and functionality to its CR products. Technical work is focused on increasing capacity of CR devices and decreasing scan time. At the same time, the company is expanding image processing capabilities to improve image quality on both hard and soft copies. As far as functionality, Kodak hopes to expand CR into exams not commonly done on CR today, such as long bone exams. Finally, the company also is working on a stream of software-driven enhancements that will help customers maximize their investment in CR. For example, Kodak announced new remote patient data entry software at RSNA 2001. With the new software, customers can use an external PC to enter patient demographics data. The patient is cued up, and the technologist can retrieve populated patient list at the remote operations panel.

Technical CR development also is humming along at Agfa. According to Ciona, a single-plate CR reader with a new scanning engine is in the works. The new product is achieving scan, erase and display times of 10 to 12 seconds vs. the more typical 45 to 60 seconds. The new machine could match DR with respect to throughput and image quality; its capacity is 200 plates per hour. There is CR equipment currently on the market that comes close to that throughput. Fujifilm launched its FCR 5502 at the end of 2000. The cassette-less high throughput digital table can capture up to 168 imaging plates per hour. And OREX recently signed an agreement with ContextVision (Kista, Sweden) to development an image enhancement package for its CR units.

CR customers are anticipating new developments. Grady says, “We’re waiting on the new scanhead technology that should be available in 18 to 24 months. It puts the scanner in the bucky, which takes away a lot of the hype of DR.”

Another fairly new CR product offering is the tabletop CR system. These systems are designed for desktop and low-volume environments. These simple, plug and play CR systems can be placed on a cart and used anywhere in the healthcare setting. Ciona predicts, “Tabletop CR systems will be a huge market in the future.”

The end result of the enhanced products offering is a thriving CR market. “CR just may be coming into its own,” says Jebo.