X-ray Vision is Taking Over

It was only a matter of time before digital radiography (DR) would begin to make inroads in medical imaging. Industry watchers estimate about 40 percent of x-ray rooms today are supported by digital radiography (including DR and computed radiography) - and because many are workhorses in the busiest of radiology departments, some even say we've reached the crossover point that more x-rays are being created digitally today than via old-reliable analog units, which will continue in action for many, many years to come.

A series of motivating incentives including more sophisticated picture archiving and communications systems (PACS), the evolution of flat-panel digital x-ray image capture technology that yields high-quality images at lower x-ray dose, as well as the economic imperatives for increased efficiency from overburdened clinicians all converged to drive adoption of DR systems at an ever-increasing rate.

DR systems, often designed to mimic the workflow patterns of a general radiography room, have proven their value whether deployed in a hectic emergency room setting or a demanding orthopedic clinic. While PACS is often considered pivotal to making the decision to install DR, there are institutions that have not yet completed that step, who find DR still to be appealing.

As institutions make their decisions about purchasing digital radiography solutions, they must consider their patient population to justify the increased expense these systems entail. For example, smaller hospitals or clinics may not have the patient volume that will offset the expense of the purchase of this equipment as general radiography studies are notorious in their low reimbursement rates.

Vendors large and small have worked to develop the capabilities of their offerings to address economic concerns as well as enhance clinical practice through improved image quality, and speed of acquiring images. There are many clinical settings where image acquisition speed assumes critical importance, such as intensive care units or emergency departments.

Bottom-line benefits include decreased operating costs due to reduced requirements for film, processing, chemicals and archiving space for film images, as well as the labor involved in managing all of those activities.

One of the other advantages to DR over film is that with a quick review of the digital image, if a patient needs to be repositioned, that activity can be accomplished more quickly. Therefore, the patient is not inconvenienced by having to wait to have film developed, and then another attempt to obtain the quality of image that is required.

Multifunction radiography

Ralph Koenker, MD, director of radiology for Novato Community Hospital, a Sutter Health Affiliate in Marin County, Calif., speaks to the issue of efficiency enabled by their busy Philips DigitalDiagnost.  

Novato Community Hospital accomplished 24,000 exams in 2000, and 36,000 in 2003, he says. During the same period, the facility reduced the number of x-ray techs from 11 in 2000 to 10 in 2003, and reduced their clerical positions by 0.5 FTE. While they no longer needed the number of file clerks to manage films at their original staffing levels, they were able to retrain those personnel to answer phones and schedule patients.

"In terms of overall efficiency, DR is much faster than film because it's a 30-second turnaround per image as opposed to three minutes for film," says Kroenker.  "And CR [computed radiography] is the slowest, which is about four to five minutes for the tech." That is why they were able to take more x-rays with fewer technologists.

He describes that CR is no faster than film because of some of the quality control (QC) steps involved with having to package the file properly for a PACS. The other advantage of DR over CR is image size - with DR images being 3Kx3K and CR only 2Kx2K.

"Some DR units have problems with image burnout at sites where there is air and soft tissue, for example at the shoulder. With our units, that has not been a problem at all. In terms of dynamic range response curve, the ability to handle burnout, this system is very good in our opinion," he relates. Additionally, they have found that they have been able to use reduced x-ray dose, yet acquire the high quality they demand in their images.

Sutter Health has installed one of the DR units in an outpatient center to provide upright, horizontal and supine studies, which prove beneficial for ambulatory patients. The unit in the hospital has only the horizontal plate which works well in the emergency department where they do a great number of extremity exams. Finally, they have a table with a moving plate where they can do patellar (knee) views in another location.

More procedures, fewer rooms

Todd Stanley, director of radiology at Indiana University Medical Center, a Clarian Health partner, in Indianapolis explains they have seen dramatic improvements in efficiency with their three Siemens Aristo FX systems. They originally had four film-screen rooms to do general radiography studies with a great amount of orthopedic and chest work. With DR, they felt three rooms were sufficient.

"The DR has cut our [turnaround] times way down," says Stanley. "Our turnaround times used to be about 31 or 32 minutes, and with the DRs, from the time the patient arrives until the time he or she departs is now down to 17 minutes. We've reduced our FTEs from four to three." This department accomplishes between 1,450 and 1,700 exams per month.

Much of the functionality of the Aristos FX is automatic, and Stanley says that his staff adapted well to learning the system's features. The usual manual tasks such as loading and transporting the cassettes as well as centering the x-ray tube to the receptor stand have been eliminated.

"When you integrate the RIS with DR, the patient demographics come across really clean and your workflow is streamlined," explains Stanley.  

Once the patient demographics are pulled up, the C-arm and detector automatically position themselves to acquire the requested images. For example, if a patient requires typical chest and pelvic views, once that information is pulled from the RIS, the technologist must only push one button at the bedside, and the equipment aligns itself to move through all aspects of the scans from AP and lateral chest to AP abdomen.  

A trauma patient who requires an oblique cervical exam would not be required to move into a different position. Lying completely supine on the bed, the Aristos FX angles the x-ray beam correctly and lines up the detector to correspond.
The FX detector moves throughout the room, and so does the x-ray tube. While the initial alignment is accomplished automatically, the technologist can fine-tune the location, and the patient table offers a floating tabletop. All study parameters can be customized to meet individual radiologist requirements.

Efficiency even without PACS

Michelle Deneinger, RT (R), and Barbara Curtis, RT (R), both radiologic technologists at Creighton University Medical Center in Omaha, Neb., describe their use of the GE Healthcare Revolution XR/d digital radiography system. Once again, the efficiency of this DR system is appreciated.

"A trauma patient used to take us 30 to 45 minutes, and now we are able to finish a study in about 15 minutes," says Deneinger. Curtis adds that while a routine chest x-ray would take five to 10 minutes to process the film, they are now able to see the image instantly. They note that many of their patients who come in frequently have noticed how much more quickly their x-ray studies are performed, and they are intrigued by the use of computers in the x-ray exam room.
Creighton is in the process of deploying a PACS within the year, and the facility currently prints film for radiologists to read.

The technologists describe an easy training transition that enabled them to use the system within about a week. GE offered training for "super users" to enable them to help their department technicians if future problems were to arise.
While the department as a whole accomplished close to 80,000 exams, they routinely perform about 17 patient studies on their DR unit during an eight hour day - but they have done as many as 60 patients in one day.

Images, STAT

DR in the ER was the solution for Borgess Medical Center in Kalamazoo, Mich., says Julie Kendall, BS, RT(R)(M), technical manager and interim director of radiology services. They conducted an extensive search and selected the Modulaire Plus from Swissray International on the basis of ease of use and short turnaround times for their imaging studies in this Level 1 trauma unit.

Borgess has experienced improved throughput, with images to review within 10 seconds that they archive and distribute immediately. An emergency department chest exam that formerly took 10 to 15 minutes to complete now requires only five minutes with an experienced technologist.

This 365-bed medical center installed one of the newer DR units from Swissray, the Combi Plus, in their main department. As a beta test site for this system, they have been engaged in collaborative activities with the company. "This has been an excellent company to work with in terms of their response to our needs," says Kendall.

"We have purchased two new Modulaires and two Combi Plus units for our new outpatient care facility that will be opening in August," Kendall concludes.

Good bones

Brent Colby, medical physicist at MeritCare Medical System in Fargo, N.D., selected the Kodak Healthcare DR9000 system to reduce the number of x-ray rooms they ran in a large orthopedic clinic. As an organization, they accomplish a total of 300,000 imaging procedures per year.

They complete approximately 1,600 x-ray exams, primarily orthopedic, per month in the Southpoint Clinic, and consider the DR9000 the workhorse. Colby describes outstanding image quality, while he is satisfied with the dosages required.  

"We've been very pleased with this unit, and we'll install another one this summer in our pediatric clinic," says Colby. The combination of excellent image quality with low x-ray dose makes this solution particularly appealing for pediatric cases. Meeting the challenges of imaging young patients requires extra consideration.

The DR9000 is designed with a multiplanar motion U-arm to enable a variety of x-ray exams including head, chest, skeletal, extremity, abdominal and exams of patients who have experienced trauma. The system includes five components with a direct x-ray capture capability, operator console, ceiling mounted U-arm, a high-frequency x-ray generator and x-ray tube, and a selection of patient tables.

Sharing space

Dave Langlois, director of radiology at the Eisenhower Medical Center in Rancho Mirage, Calif., opted for an Anexa Corp. SyneRAD Multi in their emergency department when they needed to drop from two x-ray rooms to one with the installation of a new CT scanner.

The hospital, currently licensed for 260 beds, is scheduled to increase to 400 beds within the next couple of years. Their business is considered seasonal with the height of their census from December through May. In the summer months, many of their base of 300,000 citizens leave the area to escape the heat.

Eisenhower selected the SyneRAD Multi because they wanted user-friendly systems for their technologists. "We chose Anexa because it had an overhead tube stand, something a tech could grab onto and handle as he or she had before," Langlois says. They did encounter some challenges as they moved from CR to DR, thereby causing a change in workflow. They had been using CR for five years prior to adopting this new approach. However, their throughput has increased significantly as their techs became comfortable with the new equipment.

DR for outpatient imaging

An Imaging Dynamics Co. Xplorer 1600 was the right choice for Clark Saylor, director of purchasing for Universal Health Services in King-of-Prussia, Pa., who was purchasing the unit for an outpatient clinic associated with George Washington University in Washington, D.C.

Saylor anticipates a significant increase in throughput with the system, which utilizes CCD detector technology vs. the flat panels used in the other DR units, and says that the radiologists and radiology administrator at George Washington say that the image quality is one of the best features of their DR unit.

A typical conversion of a standard x-ray room with two buckys to DR would cost approximately $500,000 to $600,000, and given the usual reimbursement rates for general radiology, it would take several years to break even without dramatic increases in throughput. With the IDC equipment, a system such as the Xplorer 1600, runs about $200,000.

Fewer repeats

Annette Tremallo, RT (R)(M), site supervisor for Trumbull Advanced Radiology Consultants in Trumbull, Conn., was part of the team that arranged the October 2004 installation of Quantum Medical Imaging's Q-Rad-DQ digital system, using the CMT SmartRad receptor.

"Our radiologists were amazed with the detail of what they could visualize on a chest x-ray," says Tremallo. They saw their "repeat rate" decline because they could window and level to improve the image as needed. Quantum Medical Imaging established set protocols that Trumbull used initially, and then their radiologists fine-tuned the techniques depending on their individual preferences.

The practice has used digital imaging for other modalities, with referring physicians being able to login and view images. When their physicians realized they could follow the same pathways to view chest x-rays, and didn't have to wait for films to be sent, they were delighted.


Digital radiography is clearly gaining momentum. As radiology departments, freestanding imaging centers and other healthcare settings work to decrease costs and increase their efficiencies while improving staff utilization, they are looking toward DR for help. The continued growth in PACS deployment should serve as further impetus to adopting this technology.