photoA year ago it was the big question on everybody’s mind in the radiology industry. It would decide the future of radiography and thus, the vast majority of work in the radiology department. DR or CR, which would win out?

As digital radiography (DR) seemed to be gaining steam, many market watchers wanted to know what effect this new technology would have on the already established digital technology computed radiography (CR). Manufacturers on both sides volleyed back and forth about workflow, cost and image resolution benefits. Each side trumpeted the advantages of its technology, but in the end, it was the clinical sites that may have answered the pressing question. DR or CR? How about both.

For the most part, the debates comparing and contrasting the two technologies have subsided. There are some manufacturers on both sides that prolong it, but in general we know that DR, when running smoothly in a high-volume environment, is more efficient than cassette-based CR with its bulky plates and centralized reading stations. We know that DR costs significantly more than CR. We know that both are more efficient than film, but require an increased investment. And now, we’re starting to know that the two technologies can – and may have to – co-exist in a digital radiology department or imaging center.

Talking across the fence
The message has been so clear from the customers that most of the major manufacturers have gotten the message. As the chart on page 70 indicates, a number of OEMs are selling both CR and DR through combinations of internally developed products and reseller agreements.

The most recent and telling of these announcements turned some heads just after this year’s Symposium for Computer Applications in Radiology (SCAR) meeting in June. Agfa Corp. (Ridgefield Park, N.J.), a staunch defender of CR’s place in the radiology department, participated in a forum discussion, toeing the company line and praising CR’s advantages over DR.

But only days after that meeting, Agfa signed a deal to resell flat-panel DR systems from Canon Medical Systems (Irvine, Calif.). Many industry watchers felt this was more than another marketing deal, but a validation of the cooperation between DR and CR. Agfa’s Ted Ciona, senior marketing manager for computed radiography systems, represented Agfa in the SCAR panel and now says the company had always planned to combine CR and DR, but its in-house development of DR has been slow in coming.

Ciona points out that Agfa was not anti-DR, but that it focused on CR because that’s what it had available. “On this side of the fence we’ve been very open to DR,” he says. “Some of the first GE DR systems are hooked into Agfa PAC systems.”

Ciona’s comments are backed up by those of Agfa’s John Glass, managing director of Agfa-Gevaert’s Business Group Medical Imaging. When Agfa purchased the PACS business of Sterling Diagnostic Imaging (Greenville, S.C.) in 1999, Glass told Medical Imaging he believes digital radiography and CR will co-exist – and prosper – in the market, but that Agfa will focus on CR for the near future. “It does not mean we will not be in the DR arena longer term,” he added, “but it’s hard to ride two horses and do it well.” Apparently, Agfa took some riding lessons.

For the past several years, Agfa has been developing a needle-shaped phosphor technology that will perform as well as the current digital X-ray systems. But as the digital X-ray market developed, Agfa realized it needed some type of DR offering until it could perfect that technology and struck the deal with Canon.

“We didn’t acquire [Direct Radiography Corp.] when we acquired Sterling and that was part of the reason,” Ciona explains. “We had this scanhead on the horizon and it was easier for us to become a third-party private label seller of Canon and get some profit in the learning cycle but the investment is not as great as the investment to purchase DRC.”

Another traditionally CR supplier, Eastman Kodak Co. (Rochester, N.Y.), also began selling DR through a deal announced late in 1999 under which Kodak would offer DR systems from various components supplied by OEM suppliers including Analogic Corp. (Peabody, Mass.), Hologic’s Direct Radiography Corp. (DRC of Newark, Del.) subsidiary and Fischer Imaging Corp. (Denver).

According to a recent report from Theta Reports (New York), “Digital X-ray Markets: Imaging in the 21st Century,” the Kodak/Analogic deal is an “indicator of interest and growth in the digital X-ray market.”

Digital X-ray Market Predictions

Projected World Market for Digital Radiography
General Radiography Systems
(dollars in millions)






Dollar volume






Unit Sales






Source: Theta Reports and Industry Sources

“The objective is account maintenance and growth,” says Brendan O’Kelley, worldwide marketing manager at Kodak. “How do we keep customers as they transition from film customers to digital? If we only offer CR or DR, our chances of maintaining those Kodak film customers are going to be limited. Not everyone is going to want DR and not everyone will want CR, and you will lose those accounts if you don’t have both technologies to offer them.”

Jane Hasselkus, worldwide category manager for digital radiography for Kodak, feels that offering both technologies can help healthcare facilities make the transition to digital more easily. CR can be used if their existing equipment if still fairly new and administrators want to take advantage of that value in moving to digital.

Not surprisingly, Fuji Medical Systems USA Inc. (Stamford, Conn.), the earliest developer of CR technology, has opted so far not to offer DR in its product line and continues to be the staunchest of supporters on the CR party line. Fuji does, however, offer a cassette-less system which automatically processes the images for high-throughput applications, similar to a DR system. And therein lies the debate, according to Todd Minnigh, national marketing manager, CR systems at Fuji and outspoken CR advocate.

“Most people think in terms of DR and CR, but we look at it more in terms of cassette-less and cassette-based systems,” says Minnigh. “The storage phosphor-based system is the cassette-based system, while the DR is more cassette-less. DR is too generic a term. I think there are significant differences between a CCD-based and an amorphous selenium-based DR system.”

One issue that the digital debate often overlooks is the future of film digitizers. As DR and CR gain more support, some feel the future for this transition technology is bleak.

“There’s a role for digitizers now, in terms of mammography and CAD and lung screening, but I think it’s a short-term thing as digital becomes more prevalent,” says Hasselkus. The Theta report describes digitizers as “an interim step taken by some toward obtaining digital X-rays.” Theta also questions the quality of the digitized images versus those from a digital image capture system.

From the horse’s mouth
But beyond the manufacturer’s sales speak and biases, clinical installations are providing valuable insight into the use of these technologies. And the message coming through is that if you want maximum efficiency in a high-volume, fully digital department you NEED both technologies.

John Crues is the medical director for RadNet Management (Los Angeles) which owns and operates the Tower Radiology imaging center in Beverly Hills, Calif., and the Orange Imaging Center in Orange, Calif. Both facilities have been using Fuji CR for about two years and RadNet installed DR systems from Canon at the facilities about six months ago.

Companies selling both DR and CR today


Status of DR and CR sales

Agfa Corp. Medical????????????

Manufacturers CR and has deal to sell Canon Medical Systems’ DR systems

GE Medical Systems

Manufactures DR and has deal to sell Fuji and Agfa CR

Philips Medical Systems

Develops both products in-house

Eastman Kodak Co.

Manufactures CR and has deal to sell DR with Hologic partnership

Siemens Medical Systems

Manufactures DR and has deal to sell CR with Fuji and Agfa

Fuji Medical Systems

Makes both cassette-based and cassette-less phosphor-based systems and sells its CR to several other OEMs

Average exam times: Cassette-based CR vs. DR


Cassette- based CR

less CR


Avg. exam times

9 to 35

9 to 35

7 to 25

2 to 4

Avg. diagnosis time (in min.)





Source: Theta Reports

While portable imaging is often cited as one of the major benefits for CR, the two RadNet centers are outpatient only and do little to no portable imaging, but still find CR has a definite role.

RadNet’s use of the two technologies at the two facilities should make an interesting case study in the future. At the Tower facility, Crues says the upright DR system is used primarily for chest imaging to maximize its throughput benefits, while the majority of other exams are done with CR. In the other facility, a more flexible DR system on a universal arm is being used for the majority of exams while CR is used sparingly for difficult exams.

Cathy Trujillo is the PACS administrator at San Francisco Kaiser Permanante’s outpatient imaging center. The center currently has three DR systems from Canon and one CR system from Lumisys Inc. (Sunnyvale, Calif.). Trujillo feels it would be very difficult, if not impossible, to cover all exams without CR.

“Most protocols are standard,” she says. “Shoulder exams require an axillary view, which is a cross table exposure shot of the shoulder going from the armpit out. The DR does not have the capabilities of doing tabletop work so the CR plate is against the shoulder and we aim the beam through the shoulder to get that shot. And then the other two views are taken with the DR system.”

But despite that flexibility offered by CR, Kaiser is now nearly 90 percent DR and 10 percent CR, according to Trujillo. Being an outpatient facility is an advantage in using a DR system because having a more mobile patient population allows more flexibility in the types of exams that can be administered. In an inpatient facility, CR provides more value in portable trauma and ICU exams.

A catered affair
With all the possibilities between various types of DR and CR devices, how is a facility supposed to know how to bring its radiography exams digital? Most experts say it’s a matter of catering the equipment choices to your facility’s demands and much of it depends on the age and type of existing equipment as well as your budgetary needs.

“The customers I’ve talked to that are using both DR and CR find that the transition has to be done over a period of years,” said Hasselkus. “Customers have equipment that is of various ages and in some instances are prepared to fully take out a room and put in a DR unit and in other instances have new equipment and want to use a CR solution to take advantage of the equipment that is there.”

Combining CR and DR is not only necessary to bring all exams digital, it can make sense from an economic standpoint. If a facility has a set budget to bring its X-ray digital, it can go further by combining DR and CR.

The DR report from Theta says, “To equip all [radiography] rooms with relatively expensive DR systems could be cost-prohibitive. One advantage of CR is that it can be shared between several rooms. A combination of CR and DR might be the solution for many healthcare institutions in the near future.”

But straddling the line between film-based and digital imaging is a dangerous venture, according to Crues. While some facilities may try to make a gradual approach to the hefty investment of bringing radiography digital and replace a room at a time as money becomes available, the transition period of having half digital and half film can create more headaches than it solves, Crues says.

“You get tremendous advantages if you go completely digital but if you are part digital and part film you have a problem,” Crues explains. “Then you have to institute policies and procedures that get very complex and you’re basically working in both worlds. You have all the costs of digital and all the inefficiencies of film.”

Trujillo confirms those sentiments, saying, “Running half digital and half analog is very confusing. Sharing and comparing images becomes a hassle. If a patient from the hospital has a film done and then comes down here and has a film done, we’ve got two copies of the exam around – one digital and one hardcopy. We can digitize the hardcopy, but that’s one more step in the process.”

Walking hand-in-hand
So, the question now is not which technology is more efficient or clinically proven, but how long will the two technologies co-exist together? Most experts close to the situation feel that CR will eventually be replaced by DR when it becomes flexible and inexpensive enough to compete side-by-side with CR on a product-by-product basis. But that date may be a long way off – and just how long is a matter of debate.

“I think when the price of DR comes down to the CR level you have really good arguments on both sides,” says Minnigh.

“I think most industry experts agree that DR will be the long term technology of choice, but there is a period of 10 years here where CR, film and DR will co-exist,” says Hasselkus.

O’Kelley agrees but says the timeframe is difficult to predict. He feels that 10 years from now, CR will still be present and a very useful component of the imaging chain at most institutions. But he stopped short of predicting how much of radiography will be done with CR and how much with DR.end.gif (810 bytes)