Sometimes, it’s easy to see when your radiography equipment needs a makeover. Equipment failures, patient backlog and a disrupted workflow are all signs that your room can no longer keep up with your patient load. Determining that it’s time for an upgrade is typically easier than deciding on the ideal solution, whether it’s a full upgrade to DR and wireless flat panel detectors, new CR equipment or a DR retrofit.

Going digital eventually is the goal for most facilities, but if you haven’t converted yet, you’re not alone. According to market research group InMedica, CR equipment made up 53 percent of unit shipments in 2012, though that number is expected to drop to 35 percent by 2017. The flat panel detector market made up 17 percent ofshipments in 2012, and is slated to increase to 24 percent in the next five years. Retrofit kits, which allow facilities to upgrade to DR at up to two-thirds of the price, currently make up six percent of the market, and should rise to 11 percent by 2017. Mobile, another growth area, currently sits at 16 percent and will go up to 26 percent, while film, now at 8 percent, will drop all the way to 4 percent.

But no matter which path you plan to take, it’s always helpful to have a guide. We spoke with radiology directors, biomedical engineers and top vendors to establish the steps you should take to build the right room at the right price.

Step 1: Figure out the lay of the
First, vendors work with customers to tease out what the customer likes about the current set-up and what needs to go.

“No one’s buying radiography and fluoro for the first time,” says Richard Coronado, a marketing executive at GE Healthcare. “They might have overhead tube suspensions or floor-mounted systems. That’s an example of something that generally doesn’t change in an upgrade, because customers like to stick with what they’re used to.”

Next, vendors will ask about the room’s age and reliability. “If their room is clearly old and they’ve been having a lot of problems with it, then we might suggest a completely new room,” says Helen Titus, worldwide marketing director for X-ray solutions at Carestream. “The next question is about the amount of work they have. We may suggest a new analog room and a CR, or an integrated DR room. We don’t want to launch into a solution without quantifying an issue.”

Before making any changes, hospitals that have already taken the leap recommend communicating with other departments to get a feel for what their future plans are in terms of new specialties or star physicians.

“I think it really depends upon the direction the department is going in,” says Laura Chapman, operations manager of radiology at Newton-Wellesley Hospital in Newton, Mass. “Are they bringing in new specific surgeons or new orthopedic groups? What is their requirement going to be? That can really help guide you.”

In Chapman’s case, her department decided to match the equipment to the patient throughput and procedure type in each room.

“For chest X-rays for colds, we have plain film imaging,” she says. “Then we have some fluoroscopic rooms for procedurals and joint injections. Other rooms are DR units already, but the lower volumes still have CR.”

Rob Fabrizio, director of marketing and product development, digital radiography and ultrasound at Fujifilm Medical Systems, agrees. “For hospitals that may need advanced applications such as automated long-length stitching, a more premium automated room may fit their needs best.”

If your facility sees a steady stream of pediatric patients, a wireless DR flat panel detector could be a valuable investment. “Wireless detectors are fantastic for pediatrics because you can use them in incubators,” says Ulrich Laupper, director DR business at Agfa Healthcare. “They’re also lower dose.”

Finally, facilities should be sure to stay on top of the latest updates in Wi-Fi connectivity, a changing space on which wireless detectors depend.

“In hospitals, there’s so much EMI noise – that’s the biggest service issue with wireless panels that we have found,” says Robert Anderson, DCS technical support manager at Carestream Health. Older buildings, especially, may be challenging to equip with reliable wireless connections.

Step 2: Know thy budget — and consider retrofit
Of course, budget makes the biggest impact on whether a facility decides to fully upgrade to DR, to retrofit CR or to purchase new CR equipment. Many facilities choose to upgrade piece by piece, like the radiology department is doing at Newton-Wellesley. While that’s generally not an ideal option, as employees must maintain familiarity with different operating systems, it’s one way to transition to DR without emptying your wallet.

For facilities that lack the patient throughput to justify upgrading to DR, vendors offer plenty of CR options that can serve as useful upgrades at a lower cost.

“If you stay with CR, at the end of the day, it’s still a digital image, with the benefits that come with it,” says Pierre Niepel, director of U.S. radiography and fluoroscopy product marketing at Siemens Healthcare.

Purchasing a retrofit kit could be another good way to avoid the
high cost of DR while keeping equipment consistent.

“We’re building a new facility, and what we did was make the conscious decision to not buy DR rooms, but to intentionally buy only standard analog radiography rooms across the board, including portable,” says Michael Kliethermes, senior diagnostic imaging engineer at St. Mary’s Health Center in Jefferson City, Mo. In that way, transitioning from room to room at St. Mary’s is seamless for staff, but his facility didn’t have to spend more than management felt comfortable with.

Laupper notes that facilities can also be flexible when deciding how many wireless, tethered or wall-mounted detectors to buy.

“I would always put a fixed detector in for chest imaging, but everybody’s be a fixed detector in the wall stand, and wireless in the patient table. Or if you don’t have the budget, you can start out with one wireless and add the fixed detector later.”

Step 3: Watch your workflow
Is your staff always running around frantically, or are there long lulls that leave employees idle? Taking a good look at your facility’s or department’s workflow is an important step when considering new radiography equipment. In fact, when it comes down to it, improved workflow is the most significant benefit upgrading offers, as reimbursement is the same whether the facility is using film, CR or DR.

For busy facilities, DR tends to be an obvious choice. Workflow was one of the main deciding factors for Westmed in Westchester, N.Y., which went fully digital at all of its sites back in 2006.

“We can end up seeing more than 100 patients in a day,” says Viviana Ruscitto, director of diagnostic imaging at Westmed.

“If patients are having multiple exams, that could be more than 100 on one system.”

Though more expensive, DR can also be a useful upgrade for facilities that are short on staff because of the faster acquisition time and decreased handling by staff — images appear in seconds rather than minutes, and there are no tapes to move. There are also workflow benefits for patients.

“Most DR systems can be fully automated, where you press a button and the system will automatically go into a position,” says Siemens’ Niepel. “It improves not only productivity, but also patient safety because you don’t have to leave the patient alone. Anyone who has heard the skull hit the floor when the patient goes down for whatever reason understands how important that is.”

Being able to share wireless detectors between rooms offers another workflow benefit.

“A couple of weeks ago, one of my retrofitted rooms went down on the X-ray side, and we had dropped a detector for one of the portables so that needed to be replaced,” says Mike Foley, director of radiology at Tufts Medical Center in Boston, Mass. “We were able to take a detector from the X-ray room and use it on the portable, so it wasn’t down for the weekend.”

Step 4: Don’t forget fluoro
Though fluoroscopy has a bit of a reputation for being an outdated modality, it has a few new uses up its sleeve that may convince buyers it should not be forgotten. In fact, the fluoroscopy market is expected to grow at a rate of 2.5 percent from 2012 to 2016, according to a report by Research and Markets. That being said, hospitals aren’t looking to break the bank when fluoroscopy equipment needs to be replaced.

Siemens launched the Luminos Agile two years ago, and the company is excited about new uses — and sources of revenue — for the technology, such as in fertility studies.

“In the procedure, they inject dye to show if there’s something blocking the fallopian tubes, or if the shape of the uterus is abnormal,” says Laurie Falk, clinical product manager at Siemens Healthcare. “Fluoro is also low dose and very fast. And for this procedure, patients may pay out-of-pocket, so it can help you capture more revenue.”

Fluoroscopy is also being used in speech studies for patients who have had strokes or tumors in the neck area that impact swallowing. “The speech therapist wants to look at the function at the back of the throat, so they watch as the patient is swallowing,” says Falk. “That way, they can tell if the patient can get off liquids or go to thicker consistencies, or finally go home.”

Step 5: Maintenance myths and questions
Though the workflow prospects are exciting, users sometimes have a few fears surrounding DR-upgraded rooms. For example, some facilities may shy away from wireless panels out of fear an employee with butter fingers will drop the plate, leaving it with a shattered screen, iPhone-style.

St. Mary’s Kliethermes says it generally costs $5,000 to $8,000 to insure a panel. “How many years would you have to not drop a panel to make up for that cost? That’s going to be a per facility decision,” he says.

Tufts Medical Center’s Foley, who had a panel break recently on a mobile unit, says the risk depends on how the detector is used. “I look at it separately. The detectors in the X-ray room might be safer because they don’t travel as much. In the portable environment, you’re up in the ICUs, putting these plates in bags, moving patients, so they drop every so often,” he says. But Foley also notes that the detectors are sturdy, not fragile like glass.

Plates aren’t the only concern. Sarah Jones, an analyst at the research group In- Medica, says that she has heard from manufacturers that some are concerned about where liability falls if something goes wrong with a piece of retrofitted equipment.

“No one has said this has happened yet, but it’s something a lot of the manufacturers are slightly concerned about with regards to the retrofit market,” says Jones. “Because the market is still in its infancy, it’s quite a new technology, I’ve not heard of any specific issues yet, but people think it could be quite a potential issue if things happen.”

Foley had a similar worry. Because he retrofitted his room from one vendor to another, he was concerned that it would be difficult to know which side was to blame when something went wrong. He has found that because the retrofit bypasses the generator function, when there’s a problem, it’s clear whether it’s from the generator or the retrofit portion.

“You’re really working independently,” he says. “And with the Carestream system we use, if you have a problem with the retrofit side, you can flip a switch and it can go to the other vendor’s generator.”

On the biomed side, Kliethermes also does not see liability being an issue. “Back in the day, you could have asked, was it Agfa or Curex film?” he said. “I don’t see that as an issue, because X-ray is X-ray.”

With more involved technology, service contracts can be more expensive for digital rooms than for analog rooms. Kliethermes notes that service contracts for DR retrofit rooms tend to be more flexible than service contracts for DR rooms.

“If your in-house staff did not have the capability to work on the digital portion of the R/F room, but could work on the X-ray portion, it would be very unlikely that an OEM x-ray vendor would separate the digital and X-ray areas from the contract and in the end you would end up with a contract on the entire product,” says Kliethermes.
“With a DR retrofit solution, however, you have the ability for your less experienced clinical engineering staff to continue to maintain your X-ray room solutions and either contract separately for the DR retrofits or just go with a drop insurance coverage plan for the digital plates only. Essentially there is more flexibility with the analog Xray room fitted with a DR retrofit and you are then not at the mercy of the OEM X-ray vendor.”

Once your service contracts are arranged and regular maintenance check-ups are in place, your new R/F should serve you well for years to come. . . or at least until he next irresistible upgrade comes along.

DOTmed Registered Rad/fluoro - DMBN November 2013 Companies

Names in boldface are Premium Listings.
Domestic
Elie Semaan, Rayon-x Engineering, LLC, CA
DOTmed Certified
Christine Holland, Parker Medical, Inc., CT
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
Jeff Sirk, Majestic Medical Solution, LA
Fabio Cortes, FECC, NY
Lenny Place, Aramark Healthcare Technologies, TX
Joe Bradley, RolleSolutions Inc., CA
Aaron Ybarra, Toshiba America Medical Systems, CA
Robert Fabrizio, FujiFilm Medical Systems, USA, Inc., CT
Steve Layton, Steve Layton X-Ray Services, Inc., GA
Helen Titus, Carestream Health, NY
William Fries, Medical Imaging/IMCO, Inc., PA
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
Robert Serros, Amber Diagnostics, FL
DOTmed 100
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Robert Manetta, Nationwide Imaging Services, NJ
DOTmed Certified
DOTmed 100
Ryan Gilday, Clinical Imaging Systems, Inc., NY
DOTmed Certified
DOTmed 100
Ian Alpert, Tandem Medical Equipment, NY
DOTmed Certified
DOTmed 100
John Kolleger, Bayshore Medical Equipment, Inc., NY
DOTmed Certified
DOTmed 100
Tony Smith, Classic Diagnostic Imaging, OH
DOTmed Certified
Brian Doak, Radon Medical, VA
DOTmed Certified
DOTmed 100
Trey McIntyre, International Medical Equipment & Services, SC
DOTmed Certified
Ray Russell, Agfa Healthcare, SC
David Trask, First Call Parts, VA
DOTmed 100

International
David Lapenat, ANDA Medical, Inc., Canada
DOTmed Certified
DOTmed 100
Jose Morillo, J Morillo Sistemas Biomedicos, Venezuela