Like many industries, radiography continues to be an employer’s market. The number of budgeted full-time radiography employees per facility has declined over the last decade, from an average of 10.1 in 2003, to an average of 9.2 in 2013, according to a recent survey by the American Society of Radiologic Technologists. Also in 2003, 10.3 percent of the positions in radiography went unfilled, versus just 1.7 percent last year.

In a study published in the Journal of the American College of Radiology in January, researchers analyzed the ACR job board between October 2010 and June 2013 and found that on average, there were twice as many job seekers as jobs each month.

At the same time, the number of people taking the certification exams has declined. Slightly more than 13,000 people took the 2013 exams in radiography, nuclear medicine technology and radiation therapy for the first time, with the numbers trending downward since 2008. Still, it’s probably no surprise that radiography remains the most popular discipline.

The most recent census from the American Registry of Radiologic Technologists found that as of September of this year, there are 307,275 certified and registered radiologic technologists, with some holding one or more additional certifications, including 55,292 certified and registered in CT, 31,515 in MRI and 836 in ultrasound.

Shift to digital in education
While radiography hasn’t changed much since X-rays were discovered in 1895 by Wilhelm Röntgen, how technologists capture the final images certainly has. That change has been accompanied by a shift in the education of technologists.

Joey Battles, director of Educational Eligibility at the ARRT, says an overexposed radiograph, which would look dark on film, can still look good with digital, and Battles says it’s become a trend to overexpose patients to radiation and then lighten up the image for the radiologist,though manufacturers have been combating “dose creep” with image processing and dose tracking software. “People used to learn optimal techniques because you couldn’t change the image,” Battles says. “You still want to evaluate your patient and use the optimal techniques from the get-go.”

According to a 2012 white paper on best practices in digital radiography published by the ASRT, technologists should select the appropriate exposure technique factors — including kV and mA, exposure time, and the X-ray source-to-image distance — for the patient’s size and condition.

There are 850 radiography specific education programs, including a little more than 100 hospital-sponsored programs, in all 50 states and Puerto Rico, according to the ARRT. A true radiography program is 24 months of full-time education, including clinical time, whether it’s an associate’s or a baccalaureate degree program. For the clinical component, hours range from low of 1,200 to a high of 2,000. Generally, hospital-based programs have more clinical hours.

Quick return on investment
Just as the images taken with direct digital radiography appear in seconds, the return on investment was fast when Presence Saint Joseph Hospital in Elgin, Ill., received a Carestream DRX-Revolution mobile X-ray unit last December and installed its new DR room in February. It helped that a state grant and contribution from a local radiology group allowed the 184-bed hospital to make the switch without the high upfront costs — the main barrier for many facilities in upgrading from computed radiography to faster and more efficient digital systems.

“It was a very easy switch to make,” says Sandy Lancaster, the manager of medical imaging for Presence Saint Joseph. Out of the 85,000 imaging exams done each year at Presence Saint Joseph, Lancaster estimates that around 30,000 are X-ray. Before, the average patient could spend up to 10 minutes in the room for a chest X-ray with the CR technology. With DR, the time is cut to as little as two minutes. Improved image quality means radiation dose has also been reduced by up to 40 percent, Lancaster says. “We consider not just the monetary return on investment, but more importantly the patient safety issues and our productivity,” Lancaster says.

A 2013 survey by the American Society of Radiologic Technologists of more than 1,000 department managers and directors of hospital-based radiology departments in the U.S., working in different modalities and specialty practice areas, found that the average medical imaging facility has 4.5 X-ray machines and examines 20,326 patients each year. By comparison, facilities have an average of two CT scanners and examine 10,279 CT patients annually. They also examine 6,457 patients each year on average using ultrasound and an average of 4,272 patients using MRI.

Though CR is still in use, the buying trends have dramatically shifted to DR. Michelle Edler, general manager of Global X-ray at GE Healthcare, says 95 percent of the company’s sales are in DR, with the vast majority from integrated systems sales rather than digital upgrade kits.

It’s clear that greater productivity is the key to running an efficient imaging department. Hospitals are continuing to buy new equipment. A report released last year by market research firm IMV, found that 60 percent of U.S. hospitals were planning to purchase at least one DR or CR unit by 2016, a 4 percent increase from 2010. Of those planned purchases, 90 percent will be DR units, while just 10 percent will use CR technology. The survey also indicated that 40 percent of hospital radiology departments already have DR technology, while 59 percent use CR technology.

Lorna Young, senior director of market research at IMV, noted in the report that these purchases are being planned even though the total volume of X-ray procedures is declining, with a move to other modalities, such as CT, and because imaging is being done more often in non-hospital locations.

In 2013, an estimated 159.7 million X-ray procedures were performed in 4,960 U.S. hospital radiology departments using fixed generalX-ray equipment, according to the IMV report, compared with an estimated 182.9 million procedures conducted in 2010. The decrease in the number of procedures, along with the increase in productivity from DR units, may lead to a reduction in the number of Xray rooms necessary, the report states.

David Webster, vice president of global sales and marketing for NeuroLogica, a subsidiary of Samsung, makes a strong prediction that in the next five years, the industry will see 100 percent turnover from CR to DR. However, for now CR is still alive. George Curley, senior sales marketing manager for digital imaging at Agfa, says the company has sold a lot more multi-plate CR systems than they’ve expected because of hospitals faced with budget constraints. There are now smaller tabletop CR systems that weigh 70 pounds.

“They’re the size of what laser printers were a few years ago,” Curley says. Meanwhile, film is still in use, though not at many hospitals. IMV found in 2013 that 1 percent of the installed units in U.S. hospitals used film, down from 4 percent in a report IMV published in 2010.

While it’s not clear exactly how much hospitals save by forgoing film, Robert Fabrizio, director of marketing for digital X-ray at Fujifilm, says DR typically improves efficiency by two times, meaning one DR room can handle the workload of two analog or CR rooms.

“We are seeing when a site upgrades one room at a time to DR, their technologists will naturally gravitate to the new DR room, Fabrizio says. “The hospital also begins to see a dramatic increase in their workflow efficiency. The resulting improved workload capability brings with it all the discernible benefits of DR, such as lower dose and higher image quality.”

A 2012 article in the Journal of Urgent Care Medicine estimated an annual savings of nearly $15,000 for a sample start-up urgent care facility using a CR filmless operation versus digital and assuming eight studies per day, seven days a week.

The rise of urgent care and the ‘value’ market
It’s not only hospitals that are looking to make the transition. One of the key trends is that facilities of all sizes are moving to digital. “We’re really seeing growth in the nonhospital market — smaller imaging centers, clinics, chiropractors,” says Helen Titus, Carestream’s marketing director of X-ray solutions. However, some smaller facilities and practices don’t have the volume to justify the cost of moving to digital, so Carestream still has a full CR product portfolio to meet their needs.

“I was surprised at how many chiropractors do X-ray,” Titus says. “Some are still on film and making the decision to move to CR.”Titus says that gives them a way to move into digital at a price point that makes sense. Some companies are meeting that need by offering more basic equipment for facilities that lack the high volume to justify more robust systems.

Joyce Peterson, director of sales and marketing at TXR, says the company’s primary markets are urgent care facilities, orthopedic practices and chiropractors. In the last year, much more equipment has been going into new urgent care facilities.

“In the markets we’re covering, cost is a big consideration,” Peterson says. “With our X-ray equipment, you can start off with a very basic unit and add features that can help with productivity. We’re finding that many of the buyers are very price conscious, so they will forgo these features for a lower price. Especially with the urgent care centers.” Philips is also entering the “value” market and is introducing the DuraDiagnost Compact room, a small, multipurpose, floorbased DR system

Institutions that didn’t have the money to upgrade now find they’re able to thanks to systems like DuraDiagnost, says Georg Kornweibel, director of field marketing at Philips. “Traditionally, we are a leader in premium imaging. So for Philips, it’s a new segment.”

Dollars and ‘sense’
Canon recently unveiled a new technology at AHRA in August that company officials say is a cost effective way to transition to DR. The RADpro Delinia 200 digital acquisition X-ray cart uses a Canon detector with autodetect software. When the cart is wheeled into a radiography room, it senses and then syncs to the existing CR X-ray source and can acquire digital images. “We believe it’s one of the first new products available in DR in the last 10 years,” says Tim Willard, national sales manager for Canon Healthcare Solutions.

“There’s no installation needed and it can be an alternative to DR retrofits for certain facilities,” Willard added. With a preliminary $89,000 list price, the cost of the Delinia 200, about the size of an EKG cart, is similar to that of a fixed room upgrade — a recent report from MD Buyline notes that a digital retrofit can range from $65,000 to more than $100,000 — Willard says there’s a savings for facilities that need to upgrade more than one room.

“You don’t have to do three room upgrades to make your entire department digital,” Willard says. Facilities can also have an older portable and move the Delinia 200 between different operating rooms, around the emergency department and into the neonatal intensive care unit. Other budget-friendly options abound. In April, the FDA cleared Siemens’ Multix Select DR floor-mounted radiography system, designed specifically for small hospitals and imaging centers with space and budgetary constraints. The system comes with no overhead construction and has a small footprint, with the generator integrated into the table. Viola Fernandez, Siemens’ radiography product manager, says the Multix Select DR has the full benefits of a digital system with a smaller price tag.

“You can perform any clinical application you need with that,” Fernandez says. “It’s a smaller system, but it can work for every customer.” Since the system can easily fit into an existing X-ray room, the Multix Select DR is a good match for facilities that don’t want to embark on a construction project, Fernandez says. It can be an option for urgent care centers that are required to have X-ray, but don’t need the same bells and whistles for a kid who falls off a bike. It can also be cheaper than a $100,000 retrofit. “You can actually get a fully new system with a table and a wall stand for a similar or lower price,” Fernandez says.

The release of the Multix Select DR is in addition to the Ysio Max, Siemens’ high-end DR system, which was granted 510(k) clearance by the U.S. Food and Drug Administration earlier this year. The Ysio Max system includes three new detectors, including a lightweight 10x14 wireless detector, and new automation tools, such as a new feature that displays the current detector angle on a color touchscreen, eliminating the need to guess how to position the angle of the X-ray tube correctly.

Viztek recently came out with a flat panel detector that the company says can be used to retrofit an existing CR setup to a full flat panel DR at half the price. The ViZion DR + is about $35,000 to the end users, says Josip Cermin, Viztek’s president. Cermin says the low price is based on the predicted sales volume — the company expects to sell more than 1,500 units and already has back orders.

“It’s very advanced technology as well,” Cermin says. “The new panels incorporate technologies and features that were previously only available in the most expensive and advanced panels.” Agfa HealthCare has developed a consultancy program that allows facilities to weigh their various priorities and rate what is most important. For example, dose is very important for pediatric hospitals, while for some large health care networks with old equipment, DR retrofits may be the best option.

“There’s an awful lot of time savings in taking portables to DR,” says George Curley, senior sales marketing manager for digital imaging at Agfa. According to Curley, with some of the newer portable options, there can be improved efficiency even when compared to older fixed units retrofitted from CR to DR.

Agfa is also doing a major launch of its new X-ray room, the floor-mounted DR-400, ideal for a facility that can’t use an overhead X-ray tube. It also integrates Agfa’s acquisition station with their X-ray control. “It’s going to be a very high-quality, yet affordable, system,” Curley says.
Pure DR
Samsung, which purchased CT maker NeuroLogica Corp. last year, has been making inroads into the radiography market. NeuroLogica’s Webster says that with no CR carryover, it can focus on new advancements. A year ago, the company released its first DR system, the Samsung XGEO GC80.

“Everything we did is designed with DR in mind,” Webster says. “It’s a much smoother experience.”
The company focuses on improving image quality for its displays, which in turn, lowers radiation dose. “Samsung wasn’t the first company to put out a smartphone, but now they’re the world’s leader,” Webster says. “What Samsung does really well is take a digital technology and perfect it.”

From a flip phone to an iPhone
With the trend moving toward smaller and more lightweight detectors — Fujifilm released a 24x30, four-pound detector in 2012 — service has also become an important aspect of any DR system. According to a report last year by MD Buyline, service fees have climbed to $30,000 to $55,000 for digital systems, versus $8,000 to $12,000 for analog X-ray systems. But options and customization levels vary.

For instance, Fujifilm offers a service called Active Line Monitoring, an option for customers to be connected to the company’s service headquarters and have error codes from any system tracked and logged. “If the administrator wants an email every time a detector gets dropped, we can trigger an e-mail alert,” says Fabrizio of Fujifilm. “It’s a huge help for hospitals that are hard to get to from a service standpoint. A lot of troubleshooting can be done from the active line.”

Fabrizio likens the more fragile DR detectors to moving from a flip phone to an iPhone. “The users need to be retrained to really handle the detectors with more care and in full understanding of the scope of how expensive they could be,” Fabrizio says. “That said, they are getting more rugged and lighter.”

Dose detection
While lowering radiation dose is a bigger issue in the CT market, it’s still a priority for X-ray, with manufacturers and third party companies offering image processing and also dose tracking software.

“The U.S. market is becoming much more conscientious and aware of dose,” says Carestream’s Titus. “Facilities are asking about how much dose is required to get a good image and they’re much more aware of it than in the past.”

Carestream’s software provides X-ray techniques and image processing that’s unique to different body weights and sizes and also monitors dose, Titus says. Fujifilm’ Fabrizio says the company’s 24x30 detector reduces dose by 40 to 75 percent and the company’s D-EVO Suite II has dose tracking, providing warnings when the technologist is outside of the recommended range.

Agfa’s Curley says the company’s MUSICA image processing software allows technicians to lower the dose and get better image quality, something that hospitals and imaging centers are touting in marketing messages in an effort to stay competitive. The overarching message from the facility is, ‘We’ve got our eye on this,’ ” Curley says.

Lancaster, of Presence Saint Joseph, says new technologists pull up what the techniques are in order to optimize the image for different types of exams, instead of using too much radiation as they might in a CR room. DR technology also makes it possible to track the lifetime monitoring of dose, which is especially important in pediatrics. “Information on dose is much more readily available and is available to the patient,”Philips’ Kornweibel says. “That’s not really available on an analog system.

Hospitals need to show they have these programs in place that prevent too high of a dose used on a patient.” Image processing software has also advanced. Viztek recently introduced its new Ultra DR software at this year’s AHRA conference. By the time RSNA’s conference takes place, the company plans to have a message on its software, at the request of a client, reminding technologists to check if they have lead markers in the field. “It’s really not about [the] panel anymore, it’s about a software that can manage systems,” says Bruce Ashby, general manager of Viztek. “How do manage workflow to reduce dose.”

Fluoroscopy maintains its intensity
New fluoroscopy products are also heading to the market. In April, Shimadzu received FDA clearance to market the Sonialvision G4, a digital R/F table system for a wide variety of examinations, including angiography, endoscopy, video fluoroscopy, orthopedic exams, and general radiography. One of its touted features is a table that can support a patient weighing up to 700 pounds.

Marketing manager Frank Serrao says adjustable gastric banding surgery, or the Lap Band, has to be done with fluoroscopy and many hospitals don’t have the right facilities to be able to treat morbidly obese patients. The Sonialvision G4, which has been recognized by the American Society for Metabolic and Bariatric Surgery, provides many other tools, along with the ability to remain competitive in the bariatric surgery arena. “Now we’re starting to try to give the customer more value in what they’re buying,” Serrao says.

Fluoroscopy has become a much more “stable” market, says Philips’ Kornweibel and hospitals have been trying to make their fluoroscopy rooms more productive as the overall number of those procedures remains stable or is declining. Adding DR technology can help make the room work more efficiently. “They can use it for fluoroscopy in the morning and as a DR overflow room in the afternoon,” Kornweibel says.

DOTmed Registered Radiography & Rad/Fluoro Companies

Names in boldface are Premium Listings.
Domestic
Daniel Giesberg, American Medical Sales, CA
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Rich Kimball, Imaging Innovations Inc., FL
Glenn R. Hammerquist, Berrien X-Ray, MI
Alison Fortin, Global Inventory Management, NH
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DOTmed 100
Sal Aidone, Deccaid Services Inc., NY
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Robert Muzzio, GXC Imaging, NY
Frank Serrao, Shimadzu Medical Systems, USA, CA
Aaron Ybarra, Toshiba, CA
Robert Fabrizio, FUJIFILM Medical Systems USA, Inc., CT
David Denholtz, Integrity Medical Systems, Inc., FL
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Olga de la Paz, Puma Exports, FL
Robert Serros, Amber Diagnostics, FL
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Ryan Gilday, Clinical Imaging Systems, Inc., FL
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Michael Glynn, Mylin Medical Systems, Inc., IL
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Marcel van den Bogert, Claymount Americas Corp, IL
David Webster, Neurologica Corporation, MA
Ronny Bachrach, Viztek, NC
Helen Titus, Carestream Health, NY
Nathan Layman, Radmedix, OH
William Fries, Medical Imaging/IMCO Inc., PA
George Curley, AGFA Healthcare, SC
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Scott Milgrom, Radiology Solutions LLC, MI
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James Goldner, First Source, Inc., NC
Bill Cioffi, Rayence, NJ
John Kolleger, Bayshore Medical Equipment, Inc., NY
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Tony Smith, UDR Conversion, OH
Trey McIntyre, International Medical Equipment and Service, Inc., SC
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Mary J. Lampley, J&M Trading, TN
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Brian Doak, Radon Medical, VA
Amy Belche, First Call Parts, VA
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International
David Lapenat, ANDA Medical, Inc., Canada
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Mads Vittrup, AGITO Medical, Denmark
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