CR: Radiology's Workhorse at Work

hiit040705aComputed radiography (CR) has emerged as an important alternative to traditional plain film by offering access to electronic capture and management of imaging studies. It is a less expensive option than digital radiography and therefore proves an attractive option for smaller institutions and those with budgetary constraints. As image quality has improved in CR, many facilities and departments have selected this approach to meet their digital imaging needs.

CR as the backbone of imaging

Sally Grady, RT(R), director of imaging services for Florida Hospital Celebration Health in Celebration, Fla., explains that their multi-institution network performs close to 1 million imaging studies, with approximately 400,000 to 500,000 of those exams accomplished by their 60 Agfa CR units. 

“Our radiologists are very particular about the quality of the image, but they don’t care how the image was acquired,” she explains. “Whether it took me 10 seconds with a DR or 12 seconds with CR, they don’t care so long as the end product has a certain quality.” They have now installed the new Agfa DX-S, with MUSICA2 as the latest image processing software.  The resulting images are captured more quickly with better image quality than before, Grady says. 

They installed one of the units in their Emergency Department where they anticipate having more than 55,000 patient visits this year. Eventually, they plan to replace all existing CR units in the hospital with the DX-S computed radiography systems.

Max Grady, RT(R) is the manager of imaging information systems at Florida Hospital Celebration Health, and he explains that the DX-S scan head is much faster than other systems. He says that with traditional CR, the scan is accomplished line-by-line in a registered pattern where a thin laser beam scans point by point across one row, up one line and across the next row. The  DX-S scan head is engineered to read the entire row at the one time, so it scans down the whole plate in a single motion. This capability, coupled with a new “needlepoint phosphor” image plate, offers a much higher spatial resolution and produces a very sharp image, he says.

Another benefit to this system is the small footprint (approximately 2 feet by 2 feet) that can go into the x-ray room. The cassette reader can be placed either in the x-ray room or outside the room. He says this device functions to produce an image almost as fast as DR. 

Sally Grady says, “On the expense side, capital gets more difficult every year, so for me to spend $400K on a DR system when I could outfit four or five rooms with CR that will give me almost identical productivity, it doesn’t make financial sense…And we have 55 radiologists to please.”

Improved efficiency & reliability important

Michael Walker, RT(R)(CT)(NM), manager of Robinson Imaging Center of Kent in Ohio, describes their center as a division of Robinson Hospital, which is about 15 minutes away from this outpatient campus that opened in January 2006. They offer several imaging modalities, including diagnostic x-ray with a Fuji FCR Carbon XL CR system, a 16-slice CT and open MRI plus a PET scanner. Since they do not have a radiologist on site, they send all of their images to the primary radiology department in the hospital to be read.

“The biggest thing that CR has done for us is to enable us to be an extension of the radiology department because we can send images so easily,” he explains. They have improved their turnaround time for reports dramatically, now down to 24 hours, which they use in marketing their services. Walker says they have a single load FCR cassette reader, because their workload does not require additional capabilities.

Troy D. Todd, RT(R), PACS administrator for Alliance Community Hospital in Alliance, Ohio, reports that their Fuji Carbon XL is dedicated to their Emergency Department, “Anyone who comes through the ER and who needs any kind of imaging exam, it’s done in the room with the Carbon XL.”

One feature they find helpful is the compact size and ergonomic design. With the monitor at eye level and the cassettes waist-high, everything functions without the operator needing to bend. Secondly, they consider this an extremely reliable system with no plate jams or down time since the “go-live” date in January. Todd says the cassettes are very durable and the user interface is easy to navigate.

“Another reason we chose this system is that you can easily track statistics, such as re-take analysis per technologist,” he says. This enables them to analyze whether or not a technologist is under exposing or over exposing or has problems with patient positioning. They can provide additional education if that is required, and they use this feature as part of their Quality Assurance program.

Finally, he cites the ease of integration into their existing GE Centricity RIS/PACS system. They select the patient from the worklist on the hospital’s HIS, which loads the exam and the projections for that exam.  Then all that is required is for the technologist to take the exposures, stamp them with their name and develop them. Images are stored on the PACS, and are burned to CD for copies that are needed elsewhere.

Combining CR & DR images

Erlanger Health System in Chattanooga, Tenn., is a multi-hospital system with a Level 1 Trauma Center and a tertiary referral academic hospital that performs a total of 300,000 imaging procedures per year. They have installed five Kodak DirectView CR 850, CR 950 and CR 975 systems with eight more on order. They’ve been using CR for about two years in their children’s hospital, ED, main radiology department and outpatient centers. In the trauma bay, they have a 50-inch plasma monitor mounted to the wall to facilitate reading.

Blaine Morris, MBA, RT(R), CRA, is the administrator of radiology services at Erlanger Health, and he reports that they build in redundant systems to facilitate care.

“In the ER, the reason we went with Kodak for CR and DR is because they blend so well. If they are doing a procedure on DR and they need to shift to using a CR plate, we can easily marry those images together in the same electronic file.”

The one limitation with CR that Morris cites involves imaging extremely obese patients, so they maintain plain film capabilities for those individuals. Thirty percent of their patients weigh more than 300 pounds, and they have used DR for some of those patients as well.

Sheila M. Sferrella, MAS, RT(R), CRA, FAHRA, administrator for diagnostic services, describes the Lehigh Valley Hospital system in Allentown, Pa., where they have installed 13 Kodak CR systems throughout their three-hospital/eight imaging center network. Using these CR units provides the practical means to get images into electronic format and onto their PACS. Everything is stored on an IDX Imagecast RIS/PACS. (IDX is now owned by GE Healthcare.)

Before they implemented CR, they used to courier films between their various facilities for the radiologists to read, so their turnaround time has improved significantly with this deployment.

“This has made a huge difference for the radiologists and especially the pediatric radiologists, because often they weren’t at the sites where we needed them, and it could be hours of delay before they saw the images,” Sferrella explains. 

Cathleen Story, BS, RT(R), CRA, chief PACS administrator for radiology at the Lehigh Valley Hospital describes their approach to the 120 portable exams they do each day. “At the Cedar Crest site, when the techs go to take a portable [x-ray study], they take a small [Fujitsu] Lifebook computer [with touch screen capabilities] with them to log off those cases as they’re up on the unit doing them, which saves time when they return to the department.” All they have to do is to match the images with the accession number they’ve already tracked, thereby improving their efficiency.

In designing their entire network of CR, Sferrella says it is very important to analyze peak utilization. “This is one example where averages don’t work, and where people have failed with implementation. You can’t look at average numbers of studies per hour, because then you’ll have people lined up to do studies…You have to look at your peak volume…the hours per day when you do the most studies.” Planning and decision-making should be based on peak time analysis. 
In addition to adoption of CR imaging, they bought digitizers to use for their old films so that those images could be included in their system.  And they employ a physicist to calibrate all of the x-ray components.

The Dartmouth-Hitchcock Medical Center uses CR as a secondary modality to DR, according to Jerry Bergen, RT(R), team leader for the diagnostic section of radiology. They have adopted Philips Medical Systems PCR Eleva CR system in their ER and in their primary radiology department they have used CR for three years. “We primarily use CR in areas where DR is not practical, such as portable radiography or in the OR, and those user exams where the patient cannot be positioned at a DR detector. We use CR in all of our intensive care units, because it allows us to take imaging to the patient.”

James Mood, RT(R), BA, medical imager and super-user of the PCR Eleva system says that in terms of workflow, it allows the techs to be very flexible in working with DR and CR and to integrate them in terms of image quality. “The PCR Eleva processes the image quite quickly, and what we’re seeing [in the room with the patient] as we preview the image is virtually what the radiologist will see in appearance and quality,” he says.

They have a core area with two CR readers, one on each side of the department. They have a PCR Eleva WorkSpot with a screen to takes patient data off the list and previews images, one on the inpatient side, one on the outpatient side, and a third by their fluoro rooms.

James appreciates the touch screen functionality of the WorkSpot, but some of the other technologists prefer to use a keyboard and mouse. He explains that the system was designed so that a WorkSpot can be hung on a wall if it is needed in an area where there is not enough counter space for the keyboard/mouse configuration.

Jim Roberts, RT(R), BS, clinical operations manager for the radiology department at Dartmouth-Hitchcock issues a cautionary reality. “If I had a choice to make between using CR or DR, one of the factors that would help me make my decision is radiation dose. With an identical exam, the CR dose would be four times greater than DR.” This is not unique to the Philips system; it is a technologic reality across vendors.

As a concluding comment, Darthmouth’s Bergen notes that besides increased productivity of digital imaging, speaking as a technologist, imaging in a digital environment is much more enjoyable. Technologists have more time to spend with patients, and their work time is concentrated on producing images rather than handling film. Besides, they are closer to the action, in addition to capturing images more quickly.


Computed radiography has gained a place in clinical imaging throughout the healthcare enterprise. For certain patients it is preferable to any other approach, and by enabling the capture of electronic images, it offers the benefit of image management enabled by those technologies.