Printer manufacturers aren’t exactly quaking in their boots over the idea of PACS systems and the “filmless lab.” The truth is that film usage continues to soar, and improved technology is creating new frontiers in imaging. Remember the promises of the paperless office in the 1970s and ’80s? Well, we’re experiencing d?j? vu. Despite a buzz to the contrary, film is as popular as ever in 2004. But what about the future? Will printers outlive their usefulness?

“Not in my lifetime,” laughs Tim Jablonski, VP of marketing for Codonics Inc (Middleburg Heights, Ohio). “PACS is about increased communication and increased productivity. Soft-copy viewing is becoming more and more useful, but you can’t travel around with it.”

So rather than pitting printing technology against Picture Archive and Communica-tions Systems (PACS), printer manufacturers appear to be keeping pace with PACS changes and offering printing technology that enhances the features of PACS and boosts productivity in an evolving arena. PACS and printers both have their place, depending on implementation, and radiology continues to rely on printed film.

The biggest change is in the growing popularity of dry-view printing, which eliminates many of the costs and space requirements of the more time-consuming wet-printing process. Dry-view printing allows the creation of film and paper images that are less expensive, and it eliminates many of the drawbacks of wet processing: specific plumbing requirements, chemical developers that demand special handling, and, perhaps most important, large amounts of space for dark rooms and equipment. Processors for wet imagers are stand-alone devices that require much more floor space than most of today’s dry-view printers—like the Agfa Scopix LR 5200P dry-view, with its processor mounted on the top of the printer.

Training staff to transition to PACS takes time. Most technicians already have mastered the art of reading film on a light box. Many have not yet adjusted to the idiosyncrasies of reading CRT and LCD images. With the advent of new technology, it always takes time for humans to adapt. So even the larger hospitals that have invested heavily in cutting-edge PACS capabilities are unable to completely eliminate the need for film.

But that’s just part of the story. With innovations like multi-slice CT, radiologists often are creating a great deal more images than in the past and subsequently choosing a smaller percentage to print on film.

“Media film consumption continues to grow,” says Jim McLain, senior marketing manager of hard copy for Agfa (Ridgefield Park, NJ). And the reasons are plentiful. “Many people talk about a radiology setting being ‘filmless,’ but the reality is that today’s imaging centers are ‘film less,’ in that they use less film. But in most cases, they still use film at least 30% of the time.

“Film still represents the highest-resolution approach to viewing diagnostic clinical images,” McLain continues. “Most radiologists and other users have been trained in diagnosing from film. They can view the films very quickly on the light box; they can perceive dimensionality more quickly.” The digital applications aren’t far behind, but old habits die hard, and physicians would require more incentive than they currently have to surrender their reliance on film.

“Film has a dynamic range that CRTs and LCDs haven’t gotten to yet,” says Greg Cefalo, director of marketing for digital output for Eastman Kodak’s Health Imaging Group (Rochester, NY). And as useful as the PACS systems have become, hard-copy film is still required for most practitioners to teach, share with referring physicians, forward to specialists, collaborate with one another, and consult with patients.

 Kodak’s DRYVIEW 8900 dry imager offers 650dpi on all five film sizes, which can be selected without changing film cartridges.

A Question of Quality
So far, printers still offer resolution that beats most soft-copy systems: 6-bit depth and 100 levels of gray scale are common for CRTs. Eastman Kodak’s DRYVIEW color printers, for example, have a capacity as high as 14 bits and 16,000 levels of gray scale.

The dry-view standard was pioneered in the laser printer of the 1980s produced by 3M, which is now owned by Eastman Kodak. These days, thermal and laser thermal technologies are becoming standard. With laser thermal printers, the marking of the film is done with light, and it’s developed with heat. The advantage: the light can create fine points for unparalleled precision and higher image quality. With fixed thermal printers, heat alone activates the film. The image quality isn’t as exact, but the cost savings are significant.

Codonics has developed two technologies that bridge the quality gap between laser thermal and fixed thermal printers. A proprietary technology, which the company calls a dynamic media transport system (DMTS), advances film continuously across the print head—as opposed to the traditional stop-and-start method that leaves gaps, or artifacts, in the image. The second technology involves the use of a U-shaped thermal print head that isolates each individual dot, avoiding “cross talk” between pixels, thus eliminating horizontal gaps. This feature, Jablonski says, maintains the integrity of the pixels.

“Nothing will meet or beat the dye-sublimation printer,” says Ed Najera, engineering manager for printers at Mitsubishi Digital Electronics America (Irvine, Calif). “The technology used to be analog. The new emerging technology is digital, so the image is communicated digitally to the printer, and resolution isn’t limited to the 400-line process. The result is a photo-quality image, and the durability is much better.”

In Living Color
As imaging applications have proliferated, so has the need for more sophisticated color printers that are capable of capturing the complexities of such modalities as fusion images.

“Most mammography continues to be captured on film, but we’re seeing a growing trend toward digital mammography,” says Kodak’s Cefalo. “The need to print digital mammography images requires laser imaging systems with higher resolution capabilities, which our new printer can provide.”

Color is required for just about every application, Najera says, except for Ob/Gyn and most general imaging.

Jablonski adds, “The influence of color film and paper as well as high-quality medical-grade paper are key elements in the future of printers. The ability to print color is more and more of a need as changes occur on a software level.” Color is crucial for fusion images, 2-D and 3-D models that identify layers of anatomy, and images that indicate movement or directional flow.

The Storage and Space Situation
Hard-copy film archives are easier for hospitals to maintain, says Agfa’s McLain. Many rely on film libraries where images can be duplicated easily for referring physicians. Duplication can be important in the surgical arena, where surgeons generally want to review a film before performing a procedure.

Aside from the 100-year “savability” feature, Cefalo attributes other advantages to film. For example, there’s plenty of space available for such repositories, as dry-view printers have increasingly outmoded wet systems and their unwieldy requirements.

Disappearing peripherals and space needs have paved the way to decentralized printers. More often, hospitals with the money can feasibly purchase printers for each interested department for increased efficiency. Having a dedicated printer nearby means fewer personnel running back and forth to a separate location and fewer misplaced images needing to be reprinted.

“The great thing about PACS is that you can call up the image wherever you are,” says Evan Krachman, marketing manager for dry-film imagers and printers at Sony Medical, a division of Sony Electronics (Park Ridge, NJ). “But as the CT and MR systems have gotten more advanced, [physicians] want to see more.” So the systems take more images, and physicians want to compare them side by side, which is still much easier to do with large images on light boxes than with computer monitors.

The thing with the “filmless” office, Krachman says, “is that you must have a film to take to a referring doctor. We’re still not in a broadband world. There is a lot of film generated in PACS areas.”

In response, Sony has focused on what seems to be the most important trend in printers: decentralization. By creating more compact units with easy-to-use features, manufacturers are encouraging hospitals and large imaging centers to purchase separate printers for each department.

 If space is an issue, the FilmStation from Sony can stand upright, directly under a desktop. And two printers can be linked together to produce 130 films per hour.

“In the past year or two, the trend is to smaller, decentralized printers. Being able to make a compact unit that still provides enough throughput for efficiency [is our focus],” Krachman says. “We’ve been very successful with miniaturizing—just think of the Sony Walkman.” The company’s brushed-aluminum FilmStation fits underneath a desk and can be placed horizontally or vertically, with a 10-inch width and 7-inch depth.

“The location of images is key in a radiology department. People’s time is very expensive,” Codonics’ Jablonski explains. And having dedicated printers for each department helps protect confidentiality by keeping images nearby. A Codonics printer has a very small footprint, taking up just 2 feet of desk space and weighing in at less than 70 pounds. Just as important, Jablonski says, the unit plugs into a standard outlet rather than the 220-volt drops required for many competing products.

Productivity in today’s imaging centers is vital, and efficient printers are designed to maximize workflow. Kodak’s newest printer, the DRYVIEW 8900, was unveiled at RSNA in November 2003. It features a six-bin film sorter that can accommodate any film size. Kodak plans to launch the product in Q2 2004. “Often, CT/MR have their own dedicated printers,” Cefalo says. This multi-film–size printer can accommodate the other departments that print films and remain an economical choice for centers that want to get rid of wet printing altogether.

 With its compact size, the Agfa DRYSTAR 5300 dry imager is designed specifically for tabletop use.

Agfa’s Drystar printers are also portable desktop units designed specifically for the decentralized printing environment.

Looking to the Future
The future of printing will continue to parallel the future of the imaging technology, experts say.

Sony’s Krachman points to the continuing trend of decentralization. “The new printers will be smaller, more compact, and faster to keep up with the demand of workflow,” he says. “There haven’t been an overwhelming amount of advances in imaging, except in nuclear, for the past 15 years, and resolution has remained steady. Radiologists will be watching for smaller color formats.”

Mitsubishi’s Najera also focuses on productivity issues. “I emphasize that people will continue to demand speed, image quality, and the interface,” he says. “These are three areas emerging in the medical field. DICOM archiving is not likely to change anytime soon, and hard copy is always going to be there. It’s less expensive than the big systems, and experts will always want to review films.”

Agfa’s McLain explains, “There is an evolution to digital that will continue to convert the current standards. And media film consumption continues to grow.”

Finally, Kodak’s Cefalo adds, “Even as hospital IT systems have gotten more sophisticated, efficiency and productivity will continue to dominate our choices.”

The Big Eight:
Considerations for Choosing a Dry-View Printer

Don’t cart your wet-printing system to the Dumpster just yet. You’ll need to explore an overwhelming number of factors when choosing the printer that will work best in your environment. The experts recommend you examine the following:

1. Image Quality and Color. Depending on what views you’re printing, you might not need to spend the extra money for top-of-the-line image quality. According to Ed Najera of Mitsubishi Digital Electronics, modality manufacturers set the requirements for their equipment, and you should check the peripheral list in your processor’s manual to see what’s recommended. Most departments require color, but if yours does not, you’ll save money on the unit as well as the paper, film, and ink.

2. Film Size Capacity. Models with multi-bin film sorters could be ideal for imaging departments that rely on several film sizes. Otherwise, you might save money by choosing a printer that’s dedicated to the film size you use, saving both on the initial purchase and on fewer associated maintenance costs.

3. Ease of Use. If your printer interface is so complicated that only a resident expert can handle its day-to-day needs, you’ll spend more money on lost productivity. “We build our printers so anyone can load our media and print without difficulty,” Najera says.

4. Media Costs. Buying the least expensive printer doesn’t guarantee the lowest overall cost. “Media, film, and paper can add up to 10 times the cost of the hardware,” says Codonics’ Tim Jablonski. Find out which components are consumable. The cost of ribbons, paper, film, and ink cartridges can add up quickly. Codonics’ Horizon line of printers, for example, uses the company’s proprietary brand of FDA-cleared paper, called DirectVista, which costs 75% less than film. It’s the only company that currently offers color paper for medical printers. And Mitsubishi’s printers combine the ribbon and paper in one simple piece. If your printer uses multiple consumables, you might find yourself relying upon multiple vendors for media. Find out in advance where to obtain refills and replacements.

5. Throughput and Connectivity. This area can be tough to evaluate on the surface, says Agfa’s Jim McLain. Specifications don’t always match the reality. “The specifications just tell you what the print speed of the print engine is,” he explains. But the actual throughput will vary based on the answers to several questions: What is your network speed? Do you have network collisions? How fast can the printer go through a processing mode for each new patient? How do you connect? Does your system use a digital, video, or DICOM interface? Ask if the printer is truly a DICOM printer, or does it work in its own proprietary language. Translating another language to DICOM will slow the system. “Agfa printers eat, sleep, and breathe DICOM,” McLain says.

6. Service and Maintenance. How will your printer be serviced, and by whom? Will you receive direct, in-person service from the company or from an outside contractor? “Our printer’s maintenance is as simple as cleaning a photocopier,” says Evan Krach-man of Sony Medical. “You pull a lever and clean the thermal head. No service technician is needed.” Some printers require service calls to replace filters. Find out what type of service your printer will need and whether a technician is required to perform it. And, of course, find out the cost for such service calls. For example, in addition to a comprehensive service program, Codonics’ Horizon printers include a smart card with all the parameters. When maintenance is required, the card can be plugged into a replacement printer with no new programming requirements. Clearly, varying levels of service and maintenance are included with the various printers on the market or can be purchased at an additional cost. Be sure to weigh these costs in your overall cost assessment.

7. Size. Will you need to move the printer on a regular basis? If so, you might want to choose one that’s small enough for one person to handle. Ditto if you’re housing the printer in a small area.

8. Film Volume. Be sure to choose a printer that can keep up with your workflow, Krachman advises. How much activity can your system handle? Purchase a printer that can keep up with your needs and won’t require excess trips to reload the paper or film trays.


Holly Celeste Fisk is a contributing writer for Medical Imaging.