It's not brand-new, but that retrofitted x-ray system is new to you - and to your computer network. And like anything that needs to be integrated into your network, retrofits invite questions of connectivity and compatibility.
At the same time, the process of retrofitting existing x-ray equipment prompts technological considerations of its own.
The key to retrofitting is to adequately, thoroughly audit your current system and systems," advises Steve Walsh, general manager of Huestis Medical, a value-added reseller (VAR) operating largely through a dealer network. "What piece of equipment do you want to upgrade? What's the longevity, the life span, of that equipment? Does it make sense to put this new digital [flat-panel] component on it?
"What kinds of systems are in the hospital now as far as HIS [hospital information system], RIS [radiology information system] PACS [picture archiving and communications system], miniPACS?" he goes on. "Then, with the assistance of your retrofit vendor or supplier, work through your different options for hard-copy printing and network interfaces, making sure compatibility issues are touched on, primarily connectivity issues, such as, how you are going to get a hard-copy printout, and if your fluoroscopy unit is going to connect to your PACS, HIS or RIS."
If it works once, why not try it again? Mercy Medical Center in Cedar Rapids, Iowa, asked all those questions - in 2001 and again this year - and each time decided that a retrofit from Canon Medical Systems provided the best answers. One of two hospitals serving the city of Cedar Rapids, population 150,000, Mercy Medical's first x-ray retrofit integrated a Canon CXDI-31 digital radiography system with a 1994 Advantx generator and tube from GE Medical Systems. Its second, a few months ago, brought together a Canon CXDI-40G and a 1997 rad room from Philips Medical Systems. A third room, outfitted in 1999, was an original, not retrofitted, Canon CXDI-31-Trex installation.
The CDXI-31 flat-panel detector system has a 9-inch by 11-inch imaging area especially designed for pediatric and orthopedic applications, and offers flexible positioning capabilities, according to Elaine Proseus, Western region team leader and government accounts for Canon Medical Systems. The CXDI-40G, which replaces the CXDI-22, features a flat-panel detector capable of taking 17-inch by 17-inch images. A compact unit whose new smaller housing (21.65" x 21.65" x 2.65" versus 21.65" x 25.39" x 2.71" for its predecessor) more easily accommodates retrofit installations, the CXDI-40G also is available as a full system with bucky table, upright tilting wall stand, universal stand, ceiling-suspended multi-positioning unit, operator's console, control computer and power supply.
"We retrofitted to save money, and we wanted some consistency - that way the interface to the technology is the same," says Duane Dzingle, Mercy Medical's director of radiology. "When I was looking, the OEMs (original equipment manufacturers) wouldn't retrofit their own equipment. We were happy with the images [from the Canon-Trex installation], and Canon brokered the change."
Dzingle's plans for consistency extended to the purchase of a PACS and 10 PACS workstations for diagnostic and clinical use - all from Canon. The package deal also included storage: six months on-line, short-term storage and a Qualstar jukebox with 36 terabyte AIT (Advanced Intelligent Tape) long-term storage.
According to Dzingle, the Canon PACS works as a dispersed, decentralized server to send images from the three DR rooms to designated workstations. If a workstation were to go down, "I just hit a button" to reroute images to another, he says. Of the 120,000 radiology procedures the department performs a year, 50,000 are performed on retrofit DR.
Initially the radiology department worked without the retrofits' being integrated with the hospital's RIS and HIS - both Meditech products. Dzingle had no hands-on role in the integration; however, he indicates he helped make sure that Canon worked closely with Meditech to ensure HL7-to-DICOM-and-back-again conversions involving the RIS, HIS and PACS on the hospital's network: a 100 MB fiber optic backbone running from floor to floor. Copper Ethernet runs from radiology to the workstations.
"We have plans to expand [our network] to 1 GB; we put [in] switches for our PACS and DR," he says. "But the thing there is you have to make sure the vendor has a 1 gigabit output from their device. Most still don't have the capability to send it to me at that speed."
With prices for brand-new DR rooms hovering in the $425,000 to $625,000 range, Dzingle estimates he's saved at least $100,000 per room by choosing retrofit DR. At the same time, he's given perfectly good radiology equipment a new lease on life.
"I would like to think that, by doing these [retrofits], I've extended the life of my equipment," he asserts. "General radiographic rooms are probably your longest-running pieces of equipment with a life of 12 to 15 years. As long as that [detector] plate lasts, I would think I wouldn't have to upgrade those rooms for at least five, six years."
RETROFIT TIMES THREE
Extending equipment life was among the reasons that moved George Ochoa, too, to retrofit fluoro, angio and cath lab installations at Scripps Mercy Hospital in San Diego.
Ochoa, administrative director for diagnostic and clinical services, started down the path to retrofit about a year ago with a purchase order to refurbish an existing Siemens Medical Systems fluoroscopy suite. That order specified the PlatinumOne with Innovision CCD (charged-coupled device) digital camera for fluoro and spot images from InfiMed Inc.
Pleased with the quality and savings of this first installation, Ochoa returned to InfiMed a second and a third time for a PlatinumOne and a PlatinumOne DSA systems - the latter with real-time digital subtraction angiography - to retrofit a Siemens cath lab and a Shimadzu Medical Systems angio suite.
"We have a three-year-old angio system; it had eight-year-old software, so we didn't have roadmapping, subtraction, some filters and other features," Ochoa explains. "What we have here is a system that is mechanically sound, but the computer end was weak. I replaced it with the InfiMed, and now I'm going to extend the life of this product another six years.
The digital images from the three digital rooms flow to a DR Systems' PACS, exclusive to radiology. The department does not have a RIS, nor does it currently intend to get one, relying, instead, on its PACS and - at the same time - saving the hospital what Ochoa estimates as $450,000 in RIS procurement costs and $100,000 in yearly maintenance costs.
Scripps Mercy PACS Manager Jim Orlando says a brand-new HIS, LastWord from IDX, is slated to be installed in March 2004. At that time, the radiology PACS will interface directly with LastWord. Other technology driving and steering radiology's digital evolution include a Compaq Proliant server and a hospital-wide 100MB ATM (Asynchronous Transfer Mode) network, with Cisco switches, he says.
Much like at Mercy Medical in Cedar Rapids, the vendors to Scripps Mercy handled all connectivity and compatibility issues, with Orlando keeping watch, Ochoa says. Total downtime for his installation was 1.5 days, he adds. That downtime doesn't surprise Bob May, InfiMed customer care manager.
"In the old days," setting up DICOM connections was more cumbersome in that it involved knowing specific software programs and having a great deal of computer and networking knowledge. "Today, it is more like filling in the blanks," he points out, with relatively little information - IP (Internet protocol) address, AE (application entity) title and port number, for example - needed in advance of or during the integration process.
NO SUCH THING
When planning for their retrofits, both Dzingle and Ochoa did their homework, asking many of the questions that Walsh of Huestis Medical, recommends. Consider these other suggestions from Walsh:
- What are you connecting it to? "If it's just connecting to a laser printer and an R/F room, it's relatively simple: If you have no PACS, HIS or RIS, bringing your digital fluoroscopy system into the hospital is a matter of connecting to a hard-copy printer. If you have a laser printer with a local PACS that is connecting two physicians' offices in the same building, you need DICOM print, DICOM worklist, DICOM query. If you have a system that goes into a RIS, an overall larger hospital system, at that point you're going to want to move into a system that's going to give you a more complete package of storage, retrieve, modality perform procedure setup and more."
- Will the retrofit pass the system check? "The OEMS have their own software," Walsh says. "On some GE products, for example, when you turn the system on, it does a self-system check. It looks at all components: Is this tuned? Is this good? Is that right? Will a strange camera work with that, or will it be seen as an 'invader'?"
- Where do you see yourself in three to five years? "It's a lot cheaper to do it now, to get all the compatibility, at the onset. If the hospital is going to buy a PACS, HIS or RIS in two or three years, it's best to buy for that now. Make sure that the retrofitted system you buy is going to give you as many options as possible to upgrade in the future for the dollars you're spending."
DICOM in a Box (Literally)
Paul Dempster, vice president and general manager of NAI Technology Products, isn't shy about characterizing his company's product.
NAI Technology's "perfect retrofit solution" comes in a box; in fact, it is a box - The DICOM Box.
Available in five different versions for different applications, The DICOM Box is an interface that permits legacy modalities and laser printers to be put on a DICOM network. (The Web site, www.DICOMBOX.com lists more than 900 products that work with The DICOM Box.)
"Its intent is to allow hospitals to squeeze a few more useful years of life out of modalities that are still providing excellent imaging quality," explains Dempster. "It's just that they were not designed by the manufacturer to be put into a networked environment.
"We're typically talking about equipment that's three-to-five-years-old and older," he elaborates. "Pretty much anything in the last three-to-five years has a DICOM path to software directly from the manufacturer."
NAI sells primarily to original equipment manufacturers (OEMs) interested in upgrading the connectivity path in their older equipment. The company also works with a reseller-dealer network.
"What we have found is that the cost to do DICOM connectivity is still proportionally high as it relates to refurbished equipment; it's harder to justify," he observes. A refurbished ultrasound machine may cost $25,000, for example, and adding DICOM capability to that unit could cost another $12,000 to $13,000, he estimates.