d03a.jpg (8621 bytes)As digital radiography (DR) crawls onto the market, the enticing technology remains a mirage for most radiology managers, the price tag just too big a desert to cross.

Last November in “Digital Retrofits Look to Bridge the Economic Gap,” Medical Imaging reported on an option that vendors promised could turn the mirage into reality for the average facility. DR retrofits would add digital technology to existing analog equipment.

At that time, the retrofit market was taking its first steps, with just three sites installed. Here, we return to see how the market is doing and if a DR retrofit is a viable option to gain a foothold in the digital X-ray world.

The market
The retrofit market did not exactly get off to a flying start. In fact, only a few companies even are out of the blocks, several are about to make their move, and some equipment manufacturers have decided to sit this one out, preferring to put their energies into developing advanced applications for new DR products.

But the digital X-ray retrofit market is not running a 50-yard dash, proponents say. It is just gearing up for the long distance and the outlook is promising. As additional retrofit companies join and options become more plentiful, is a DR retrofit the right choice for managers eagerly awaiting the image quality and productivity benefits they keep hearing about?

That answer depends on whom you ask. Not surprisingly, the line is drawn between vendors selling retrofits and those who opted out of the retrofit market.

No one seems to dispute the benefits of a digital radiography room. The evidence is mounting – increased productivity by three times or more, less radiation for patients and better image quality. Can a facility garner the same benefits from retrofitting old equipment as it would receive from a whole new digital rad room?

You bet, says Timothy Stevener, vice president of radiology business at InfiMed Corp. (Liverpool, N.Y.). “The quality is as good and sometimes even better than what [healthcare facilities] can get from the manufacturer that they purchased the room from,” he says, adding that the productivity enhancements of instant imaging and portability is as inherent in a digital retrofit as with a new system. In addition, because much of the equipment is the same, retraining techs is minimized.

The biggest hurdle to a retrofit (an issue pressed by retrofit opponents ( is adapting a panel sensor to fit all the X-ray brands on the market, Stevener says. But, it is a mechanical problem that is easily solved and has been resolved in other applications, from replacement buckys to InfiMed’s own retrofit experience in fluoroscopy. Not to mention that many retrofit companies supply component parts to OEMs for use in their systems.

“This whole issue of integration is funny to me, because most of the companies are buying their image processors from other people and already integrating them,” he says.

InfiMed plans to install its first prototypes this fall and will be able to upgrade any X-ray system in less than one day. Its GoldOne CCD-based product uses a Trixell S.A.S. (Moirans, France) digital flat panel. The target retrofit price is below $250,000.

d03b.jpg (5712 bytes)Hologic now has upgrade kits for GEMS’s RFX and SFX tables.

Thomas Umbel, vice president and general manager of Direct Radiography at Hologic Inc. (Bedford, Mass.), says Direct Radiography has turned to other companies to help integrate its products to all of the existing systems.

Establishing a master distributor network, Hologic recently signed distribution agreements with ReMedPar (Goodlettsville, Tenn.), a unit of MedAssets Exchange Inc. (Wood Dale, Ill.), and North American Imaging Inc. (Camarillo, Calif.), a wholly owned subsidiary of DC DiagnostiCare Inc. (Edmonton, Alberta, Canada).

“With digital upgrades, you’re running into something that is a little different with each one,” says Umbel. “[Master distributors] deal with these issues every day. They are excellent partners to design retrofit kits for each of those tables and each of those applications.”

Direct Radiography, which also makes new DR systems, has not installed any additional retrofit units in the United States since the two early retrofits that went to Brooke Army Medical Center (BAMC of San Antonio, Texas) and Mt. Auburn Hospital (Cambridge, Mass.). Direct Radiography has kicked off a digital upgrade program in Europe and plans another 10 retrofit installations nationwide by the end of this year.

Umbel says the company used the early retrofits as learning tools that they now can pass along to their distributors. Both upgrades consisted of replacing an existing bucky from GE Medical Systems’ (GEMS of Waukesha, Wis.) Monitrol tables with a DirectRay digital capture array and connecting it to a viewing workstation.

The company now has upgrade kits for GEMS’s RFX and SFX tables. Umbel estimates that units selling through the new distribution networks will cost between $225,000 and $250,000.

BAMC’s experience
Rik Guinther, radiology director at BAMC, says his hospital is happy with its Direct Radiography retrofit unit, and recent software upgrades have enhanced the system even more, making the unit faster and more productive. Although BAMC originally planned to buy additional retrofits, the facility now is leaning toward buying new DR units, primarily because current X-ray equipment is either too old to be retrofitted or BAMC will go with a computed radiography (CR) system.

However, Guinther says, BAMC still is considering DR retrofits for smaller ambulatory sites, and he feels retrofits offer excellent image quality and are a good option, particularly for smaller facilities. “Instead of committing yourself, you can retrofit one room at less cost, evaluate it and see if that is the direction your hospital wants to take,” he says.

Retrofit Options: Who Has What

Company

Status of retrofit DR system

Canon Medical Systems

Offers retrofit; ten units installed

Hologic Inc.

Two U.S. systems installed; plans ten more U.S. installations this year

GE Medical Systems

Offers upgrade to own x-ray products

Imaging Dynamics Corp.

Two retrofits installed; expects 6 more in August 2000

InfiMed Corp.

Exprects retrofit prototype installation in ? Fall 2000

Philips Medical Systems North America

Offers upgrade to Bucky TH tables

Siemens Medical Systems

Offers upgrade to Multix Top tables

Wuestec Medical

Plans on entering the retrofit market slowly

Deborah Howell, radiology manager at Cherry Hospital (Goldsboro, N.C.), a 667-bed state inpatient psychiatric facility, says the facility decided to put a Canon Medical Systems (Irvine, Calif.) CXDI-22 digital bucky retrofit into a new analog X-ray machine.

“We wanted to go digital, but we were limited by the space that we had,” she says. “All the digital X-ray units out there have huge buckys.”

The hospital could not afford to make room modifications for a new larger unit and its existing X-ray machine was 15 years old. Retrofitting a new analog machine was the perfect solution. Canon connected the unit to a Kodak DryView 8100 laser imager.

“The physicians here are just amazed at how the digital quality enhances the image so much better than the old way,” Howell says, adding that the DR unit is the first step toward upgrading other rooms and eventually getting a picture archiving and communications system (PACS). That plan was encouraged after Hurricane Floyd created the arduous and costly chore of washing and drying 4,000 films stored in the basement.

Canon’s CXDI-22 can be fitted to many different systems, including universal and tabletop units. At about $225,000, the upgrade costs almost half of a new $400,000 CXDI-11 DR unit. Canon has installed 10 retrofit units and is planning several dozen more this year.

Imaging Dynamics Corp. (Calgary, Alberta, Canada) uses CCD technology in its Xplorer 1700 product, a unit that company officials expect will cater primarily to the retrofit market. As of July, the company had installed two retrofit units, with six more installations planned by the end of August. One of the least expensive retrofit options available, an Imaging Dynamics retrofit costs approximately $100,000.

“The unique thing about our technology is that it is engineered to a retrofit environment,” says Harvey Brovald, vice president of sales and marketing. “We use virtually everything that they already have with the exception of the film holders.” The system uses an autotriggering device that senses the X-ray generator and triggers the camera, without any physical connections.

Brovald says the Xplorer 1700 also is an option for facilities unsure about transitioning to digital. The system has a holder for film on the front of the digital camera, allowing customers to experiment with digital, while still using film.

“Our objective is to provide equivalence to film,” says Brovald. “If we can provide the same diagnostic quality that film does, if the radiologists can see everything they want to see and are pleased with it, then we’ve achieved our goal.”

Les Shaw, clinic director at Calgary Center for Health, says the facility’s doctors are happy with the retrofit Imaging Dynamics provided in March to its X-ray equipment. The center already is looking into retrofitting its satellite facilities as well.

In addition to enhanced image quality and productivity, Shaw appreciates the cost savings from using a digital system, namely no more film, chemicals and processing costs.

d03c.jpg (7580 bytes)Imaging Dynamics Corp.’s Xplorer 1700 contains a holder for film on the front of the digital camera, allowing the user to experiment with digital while still using film.

Deciding to go with a retrofit versus new equipment was not difficult, Shaw says. Downtime in installing a digital device was an important factor in the center’s decision, and Imaging Dynamics was able to install the digital device over the weekend and have the clinic up and running on Monday.

But cost savings – the biggest advantage to retrofits, proponents say – was a major factor in the center’s decision. “Our X-ray generator, tube, anything involved in the X-ray generation itself is still meeting all quality standards,” Shaw says. “Why spend an extra $50,000 just to be new?”

Lots of reasons, says Kevin Hobert, global business manager of radiology at GEMS. “The advantages of a whole new system is that it is all designed to work together,” he says. “Lining everything up and getting an image done is quicker and easier when you have an integrated system.”

Autotracking and automatic positioning get patients through the process faster, which helps lower costs in the long run.

Hobert says the company took a hard look at entering the retrofit market, but decided to put its resources into developing advanced applications for its new DR products instead.

“We felt that we could develop the most value for our customers by developing a new system,” Hobert explains, adding that GEMS is working on applications that rely on close integration between the generator, digital system, detector and positioner.

The economics just does not support a digital retrofit, Hobert asserts. Most of the cost in a digital rad room is in the flat panel and digital acquisition workstation, so a new system does not cost much more than a retrofit. “For a small incremental investment for the hospital, they get a lot of benefits,” he says. In addition, Hobert says installation downtime is shorter for a new DR system, a claim disputed by retrofit companies.

GEMS offers a digital upgrade to its analog X-ray products. Hobert says many customers are not ready yet to enter the

digital era, but they can buy an easily upgradeable analog system. When they are ready for digital down the road, they can have a fully integrated digital room without buying a whole new system. Because GEMS only recently began selling upgradeable analogs, no one is quite ready for an upgraded system, but Hobert says GEMS’ product is ready when the market catches up.

Philips Medical Systems North America (Shelton, Conn.) also offers an upgrade to

its own Bucky TH analog systems. Thomas Giordano, Philips’ business unit director of radiography, says upgrades comprise about 10 percent of their DR sales. All Bucky THs sold in the last six to nine months, about 3,000 worldwide, are upgradeable.

Giordano says Philips decided not to enter the retrofit market, because the final product is not acceptable in the company’s view.

“The interfaces and requirements on the system have a significant impact on the image quality that a system gives in the end,” he says. “Sure it works, but after all is said and done, the image quality really isn’t up to standard and, more importantly, if the workflow hasn’t improved significantly, than it has all been for not.”

Giordano says that for those reasons and because the cost is not substantially higher, more facilities will opt for a new system.

Siemens Medical Systems Inc. (Iselin, N.J.) is in no hurry to join the retrofit market either and is putting any decisions on hold for now. Siemens offers a digital upgrade to its Multix Top tables and is planning to upgrade a system this fall. Tom Treusdell, product manager for radiographic and flat-panel systems, agrees that a complete DR product is necessary to get the full benefits of digital. Retrofits just cannot match the workflow enhancements of a fully integrated system, he says.

Treusdell also questions the ramifications of manipulating existing equipment to add on digital equipment. For example, he asks, what happens to the warranty if the table breaks during installation or later? What happens in five years when the mechanics and generator start to go? “Do you want to put a fairly expensive piece of equipment onto something that’s only going to last another five years?” he asks.

Last November, Wuestec Medical Inc. (Mobile, Ala.) had provided the third retrofit installed at that time – a CCD-based DX-1480 installed at the University of South Alabama Medical Center (Mobile, Ala.). Wuestec officials say the DX-1480 is no longer available and they have made no additional retrofit installations, concentrating instead on the next generation of DR products, the DX2000 and DX2001 released last May. The company still plans to enter the retrofit market slowly.

Making the decision
Everyone agrees that rad rooms will enter the digital world sooner or later, but whether retrofitting to existing equipment or purchasing a new room is the best option depends on each facility’s circumstances. Factors that play into that decision include, as always, the budget. As with any new technology, experts believe the price will come down with time, giving more facilities an opportunity to join the digital revolution. However, that could be a long wait for an anxious radiology department.

Another consideration is the age of the existing equipment. No retrofit company has a hard and fast formula for answering how old is too old. Each facility must determine that for itself, looking at the amount of use, the expected life span and the economic value left in the existing system. Company officials seem to agree that anything six years or younger is worth considering for a retrofit, but even 10 years may not be too old.

The importance of extra productivity enhancements provided by fully integrated new DR systems also might factor into a facility’s decision. Despite those additional enticements, retrofit companies are betting that many facilities on a limited budget will find upgrading existing equipment the perfect solution to getting the quality and workflow enhancements only digital can provide.end.gif (810 bytes)