Digital radiography has proven itself to be an efficient, cost-effective technology.

Over the last several years, radiology departments and imaging centers have slowly shifted from expensive, analog, film-based x-ray equipment to hybrid computed radiography (CR) systems while waiting for reliable digital radiography (DR) systems to be developed.

The wait is over. Several vendors, including Carestream and Canon, have introduced DR systems that deliver results not only comparable to analog film, but at a rate much faster than its mechanical forebear.

And while throughput and efficiency are the bywords in a successful modern radiology department, DR end users are discovering that there are other benefits to entering the digital age.

The truth is that the improvement is not a matter of opinion. Radiology departments across the country are finding that—in terms of cold, hard facts—digital imaging is getting the job done faster and better.

Carestream: By the Numbers

A study of how much DR improves imaging throughput was performed in late 2006 at Roper St Francis Healthcare, Charleston, SC. The study measured the performance of a newly installed Kodak DirectView DR 7500. Jacqueline Gallet, PhD, global manager of clinical studies for Carestream, directed the study.

Prior to the installation of the DR 7500, the Roper staff had performed benchmark measures of the analog machines with the health system’s PACS system, so Gallet had the ability to make direct comparisons between the analog and digital throughput. “In a comparison between analog and digital for basically the same test, the improvement with DR was 50%,” Gallet said.

She admits to being surprised at the vast improvement with DR over analog, noting that the 50% number is the overall average, with some body parts having even better statistics. “The spine showed the best improvement at 84%,” Gallet said. Only two exam types—the hip and knee—had improved averages of less than 50%; 25% and 14%, respectively. The study was performed for 6 weeks, and, like the analog, benchmarking was measured through the system’s PACS system.

Gallet did not consider just the quickness of the scan. As part of the parameters of the study, the quality of the image was considered as well. “The image had to be readable,” she said.

Since the study was concluded, Roper has added two other 7500 machines, which were part of the system’s overall imaging strategy, according to Gallet, moving directly to digital without going through the intermediate step of CR.

Gallet said that DR has matured as a technology to the point that implementing it without an intermediate step makes sense. “It certainly has improved. It has better efficiencies, better access, and better control of the whole process,” she said.

The key reason for the improvement in throughput and image quality has less to do with the equipment—for instance, Philips and Siemens use the same DR detectors—but with the algorithms that determine the image reconstruction. “The image-quality algorithms are improving on a yearly basis,” Gallet said. “The major differentiator between vendors is their algorithms.”

One thing that Gallet did not determine was the cost-effectiveness of the DR 7500 over analog technology. “That depends on the type of patients and how many [different body parts you do]. We’ve eliminated several steps with DR, so you can get more patients through a room,” Gallet said. For instance, Roper did not eliminate any imaging rooms in light of the study, and that has more to do with the large size of the health care system’s demographic and less to do with efficiency.

Speed makes a facility not only more efficient, but it can literally buy room as well. That is what Robert Whitmarsh, RT (R), CNMT, medical imaging administrator at St Joseph’s Hospital Health Center, Syracuse, NY, recently discovered.

Capturing Space and Time

St Joseph’s is the only hospital system (as of this writing) to have a Kodak Carestream DirectView DR 9500, which is the next iteration of the DirectView 7500.

The system was installed in the hospital’s emergency department in January 2007. Whitmarsh was less interested in the system’s speed and efficiency than in its radical design. “The ceiling-suspended u-arm, along with the remote control, made it superior to other systems for trauma imaging,” he said, and echoing Carestream’s Gallet, Whitmarsh adds that the DR 9500’s image-reconstruction algorithms also made it attractive, resulting in “superior-quality images.”

Whitmarsh has several Carestream products in the hospital and plans to add two more—as a consequence of his experience with the DR 9500—in an outpatient imaging center opening next year. The reason is a question of the manufacturer’s focus on the technology. “While other manufacturers are involved in DR, we believe Carestream to be committed to DR,” he said. “Carestream is not in the business of manufacturing ultrasound, CT, MRI, and other modalities like other DR manufacturers. They are committed to CR and DR, and all of their resources are committed to these product lines.”

The DR 9500 brought more to the table than simply providing good images. It produced those images in a spectacularly short period of time—4 seconds, according to Whitmarsh. This is about 56 seconds faster than the hospital’s best CR system. The emergency department images about 8,000 patients per year.

The time savings has resulted in a cost savings. “While the addition of PACS and CR allowed us to reduce staff in our facility, DR has allowed us to reduce the number of x-ray rooms we have based on the speed and efficiency of DR compared to CR or film/screen technology,” Whitmarsh said. He acknowledges that, although the DR 9500 was priced “competitively,” the initial budgetary outlay was high, but by getting rid of rooms and eliminating film cassettes, the DR saves money over time.

DR has brought other advantages, such as decreased radiation dose. This is due in part to the instantaneous nature of the modality and the fact that images rarely have to be taken a second time. “We know right away if there’s a problem,” Whitmarsh said.

There are other reasons why the DR 9500 has saved time. Because of the u-arm, the staff does not have to use a fixed table, and, when necessary, keep the patient on an emergency stretcher. With the remote control and the ability to move the u-arm into different positions, it gives the staff more options in terms of imaging. “We can do some really wild things,” Whitmarsh said.

Conversely, the DR 9500 can be preprogrammed for routine examinations. “Instead of the tech moving it, the DR 9500 just goes to the patient, and it is ?smart’ enough that it won’t run into walls or immovable projections in the room,” Whitmarsh said.

Though the technology differs to a certain extent, the Carestream’s DR is very similar in design to its CR product. “The interface is similar to [Carestream’s] CR that makes the training easier. It looks the same, works the same, so there is no learning curve,” Whitmarsh said.

The experience with the DR 9500 came at a fortuitous time. Whitmarsh was able to eliminate the need for two imaging rooms for his new outpatient imaging center.

Carestream is not the only manufacturer that has built a niche in the DR market. Canon has also developed a successful DR system.

Canon: Smaller Can Be Better

The Everett, Wash-based Everett Clinic has nine Canon DR systems, three CRs, and one analog system spread across its central office and nine satellite imaging centers.

Karen Leppert, director of imaging for the 220-physician-owned clinic, explains that there are several reasons why she has committed exclusively to Canon. “Because our radiologists [and technologists] move to different sites, we’re trying to standardize the software and hardware. Canon is also excellent because it specializes in one type of imaging.”

Leppert emphasizes that it’s the company’s small size and commitment to the single modality that made it ideal for dealing with the 82-year-old practice’s particular needs. For instance, one of the imaging rooms was too low to accommodate the modern DR. So Canon shaved off the top of the machine in order to make it fit. “I have not seen that [sort of service] with the larger vendors,” Leppert said.

Canon proved this when it was installing the first DR in the practice. Leppert stressed that because of the high volume at this site, there could be no downtime. Canon used a portable C-arm, which allowed the site to be up and running—albeit a bit more slowly—throughout the installation. The practice uses two Canon DR systems: the CXDI-50G Portable DR and the CXDI-40EG General DR.

Leppert said that the primary reason that she has stuck with Canon is its ability to support its products. The company not only installs its products, but has also provided training, management, and advice about workflow.

Leppert said that not only is the system much more efficient to use—it is only a three-step process to make an image—but that it has vastly improved workflow. She has found that the patient-cycle time is 50% faster than CR, and, more important, the image-repeat rate is literally 0%. She attributes this to the reduced number of steps. “The more steps you have the more apt you are to make an error,” she said. She also notes that because the system adjusts and centers the area to be imaged, it also uses less radiation.

Because of the large geographic area the Everett Clinic serves, Leppert has not been as fortunate as Whitmarsh, who has eliminated rooms. She has eliminated an FTE and believes that having DR has improved morale. “The turnaround time for reports is much faster, and it is a less physical exam,” she said.

The vast area that the Everett Clinic covers ranges from sites with 30 to 50 patients per day to some with as few as 10 to 15. This means that Leppert needs options, and Canon has been able to deliver packages to fit these needs. For instance, at her analog site, Leppert is considering several options, including having a stretcher with a portable DR plate instead of a large, dedicated machine.

Having Canon as a vendor has been a positive for the Everett Clinic. However, the question remains, even with a proven product, how quickly should an imaging department move to DR technology?

To DR or Not to DR?

For Leppert, the answer is simple. “You have to look at your whole system, and as soon as you get PACS, convert immediately,” she said. “We saved between $70,000 and $80,000 by getting rid of our film storage [alone]. You have to look at your business as a system.”

Leppert adds that she will not buy a CR system and will go directly to DR when she updates her analog site. She has developed a 5-year plan to make the full transition.

Whitmarsh notes that CR allowed his department to enter the digital age, and it bought the department time while it was getting all of the pieces in place to move to DR. He said that the only time that a wholesale transition is warranted is in a new construction scenario, such as the one he has with his soon-to-be-opened outpatient imaging center.

The important thing is to take a hard look at the needs of your department. “The key to success with all of these emerging technologies is not to try to force the technology to fit into your existing workflow, but to modify your workflow to take advantage and maximize the efficiencies that the technology has to offer,” Whitmarsh said.

C.A. Wolski is a contributing writer to  Medical Imaging. For more information, contact .