The Roundtable: X-ray
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X-ray equipment is an important tool in the healthcare industry as it helps physicians diagnose and treat patients. It is also an area that has seen some recent advances. TechNation asks a panel of experts to provide insights into the world of X-ray.

The panel is made up of Michael Yester, Ph.D., head of the physics and engineering division of the department of radiology at the University of Alabama at Birmingham; Viola Fernandes, radiography product manager at Siemens Healthcare; Rick Player, president and CEO of Medical Imaging Technologies (MIT) Inc.; and James A. Monro Jr., chairman of Radiological Service Training Institute (RSTI).

Q What are the latest advances or significant changes in X-ray and in the X-ray market in the past year?

Yester: There has been a greater utilization of digital flat-panel X-ray receptors and the availability from an increased number of vendors has occurred. In addition, the use and availability of wireless digital flat-panel detectors has increased markedly.

Fernandes: The image capture device – specifically, the wireless detector – is one of the latest advancements in X-ray equipment. In terms of system capabilities, the latest trend is system automation, which is available on several systems.

Player: I think the price of digital plate technology going down has had a huge impact in our industry. As money tightens, I see a trend where hospitals are looking to cut cost wherever they can.

Monro: DR is here to stay with dependable detectors and minimal life spans of five years. Wireless detectors will replace everything built-in or tethered in less than five years. Pixel sizes will continue to get smaller producing better image quality. Dose reduction will improve patient exposure, but also will be rewarded.

Q How will those changes impact the X-ray market in the future? How will they impact maintenance?

Yester: The use of wireless X-ray detectors allows a single plate to be used in a wall or table configuration and also for direct tabletop exposures for bone imaging. The other significant change that impacts the market relates to digital portable X-ray units. This makes it easier to do bedside portables with digital detectors and not worry about a cable from the detector to the X-ray unit. If one has the proper robust infrastructure, then one can send the images back over the internal wireless network so that a portable can do many exams and have the images ready for interpretation quickly.

Fernandes: We recognized the emerging trend of wireless detectors in 2009 when we introduced our first wireless radiography system; other manufacturers have since introduced their own wireless detectors, and we see that trend continuing for the foreseeable future. In terms of maintenance, customers who are unaccustomed to handling a wireless detector recognize that it is an expensive part of the system and are sometimes initially a bit anxious about handling it.

Player: Hospitals are considering independent service companies as a way to reduce their equipment cost and service. Where before they just used the OEM for all their purchases.

Monro: For the next five years pixel sizes will shrink. So what’s next? Molecular Imaging is here already and is gaining traction. Early on it will stay X-ray and Nuclear Medicine forming a hybrid image quality beyond pixel density. In addition to better image quality, molecular imaging will use half the dose and be up to 28 times faster. Costs will plunge and throughput will skyrocket. Nano technology is still very early in development, but atomic and sub-atomic particle study has virtually unlimited potential for imaging and precision disease excision. Invasive, tissue destruction and risk of infection will be dramatically reduced.

Q What technologies are worthy of the initial investment? How can a facility with a limited budget meet the X-ray needs of today?

Yester: Digital detectors are expensive and relatively fragile and wireless digital detectors are somewhat more expensive. However, it is possible to use one wireless detector for many uses in a given room. The absence of a cord attached to such a detector helps in workflow. However, the detectors are fragile and expensive and careful handling of the detectors is crucial.

Fernandes: Customers with more limited budgets have the option of selecting entry-level systems such as an analog radiography system, which in some situations can still provide the desired patient throughput and system efficiency. Some analog radiography systems can be upgraded to digital whenever the customer desires.

Player: Facilities with a limited budget can meet their X-ray needs by considering alternatives to where they purchase equipment and services. There are highly reliable companies that perform extremely well in our industry. You need to vet them and make sure you check references but with a little homework you can save considerably on your cost.

Monro: Attitudes need to change first. The newest and latest technology is not always the solution when making an investment. Are 320 slices really necessary? We chase technology without knowing exactly why we are running. Does anyone really know how much better a digital image is than a CR image, a CCD image or an Image Intensifier image? Very few really know. First or second tier DR rooms are inexpensive, reliable, fast and easy to maintain, but we buy expensive and faster, not because it makes a difference to the patient or the diagnosis, but because we can continue to live under the OEM umbrella. The new question is not which technology is worthy of your money, but which technology can do what your patients need, over what period of time.

Q What else do you think TechNation readers need to know about purchasing and servicing X-ray?

Yester: One big issue with digital detectors, wireless or otherwise, is the replacement cost. One has to consider service contracts and work out the details if a detector is damaged or fails. Having a good relationship with the vendor is important.

Fernandes: When purchasing X-ray equipment, customers should consider system integration and the benefits of a one-vendor solution. With an OEM, everything is integrated in a system, so when you do require servicing, all parts are from the same manufacturer, making the system easier to troubleshoot.

Monro: Job security will come to those who are trained and cross-trained. If you are a BMET, then get CRES certified and PACS certified. With those credentials you are now a VIP in some very critical areas. New equipment is like a new car. You lose 30 percent of its value as soon as drive it off the lot. Whether you buy new or used, get technical training built into the purchase. Know how to negotiate a service contract. Have the OEM take care of the expensive parts and pieces. Do the rest yourself. If you need the OEM beyond year three, you are not prepared to buy this equipment in the first place. Negotiate contractual savings. The OEM is making a fortune on service. Get cut in if your facility does not exceed their estimated maintenance costs. Research the history of the department you are purchasing for, so you know how many procedures are run every hour of the day. Determine how long it will take your facility to earn back the money spent on the technology. Cut any whistles and bells not needed based on your study.

Q What are the most important things to look for when deciding whether to go with an original equipment manufacturer or a reputable third-party X-ray provider?

Yester: Other than financial considerations, an important ingredient is record of service in the area, distance of travel for response, response time and the experience of other users. One thing to keep in mind is parts availability and where the parts might come from. For instance, a U.S. company may be getting certain parts from overseas and if the part is out of stock locally, there may be customs delays. Much depends on the working relationship with a company and its responsiveness. In addition, there is a good upgrade path for any of the parts associated with the unit.

Fernandes: When, for example, you have a radiography system with a high table weight capacity and a powerful X-ray tube and generator, service is important to consider. The company that manufactured this X-ray system is the best qualified to ensure system competence.

Player: A company’s reputation is the most important thing. Ask for references.

Monro: OEMs always sell new, refurbished and up … this means they will add every convenience to every purchase. Ask how much the convenience is, and then ask how much will the system be without it. OEMs are knowledgeable, well funded, and FDA approved to do business. They can do PM, update, repair and maintain without much business interruption. They are also expensive, not only because of part prices, but also because they do not fix individual problems anymore. They fix a section of a machine. Reputable third parties need to be knowledgeable, well funded, and capable of doing everything an OEM does. Here is the rub – unless the ISO has documented training records for its staff on all the basics, pass. If they have training on your exact machine, all the better. Reputable ISOs need to be your partners, and they need to be relatively local.

Q Is it possible to keep up with the latest X-ray advances and improvements without buying brand new? What are some of the newer technologies available?

Yester: One can buy digital detectors with an appropriate computer and use them in an existing table or wall stand bucky. The same can be done for an existing portable X-ray unit with the computer incorporated into the unit. Of course the flat panels are expensive, but can be used with an existing room or portable. It is possible to use a wireless detector in several rooms or units. For instance, for a low-volume site it would be possible to upgrade a portable to a wireless digital detector and use the same detector for the portable and the standard room.

Fernandes: While the latest advancements often require the purchase of the latest technology, a budget-conscious facility can still purchase refurbished equipment from some OEMs that can provide the desired clinical capability. Regarding newer technologies that are available, wireless detectors and smaller-size detectors are on facility wish lists. Everybody wants to have them.

Monro: Research is at your fingertips every day. Industry publications are worth the time spent reading them. Visit the OEMs website. Get the brochures. Follow technical developments globally.

Q How can purchasers ensure they are making a wise investment in an X-ray? How can they ensure they will receive the necessary literature and training tools?

Yester: As with any purchase, one has to do their homework. A given vendor will have a list of customers and candid conversations with users are warranted. Concerning literature, one has to ask the vendor for any material you feel you need or any questions you have. Obviously, one needs operator manuals and applications training. Biomed training is available in many instances. For digital detectors a major concern is replacement cost; so one has to understand well all of the ends and outs of the different service structures as noted previously.

Fernandes: Customers looking to invest in an X-ray system should consider the benefits of selecting a reliable, well-established original equipment manufacturer. Choosing an established OEM will ensure that the customer receives all of the necessary literature and training regarding their particular system.

Monro: Most of this has been covered already. You don’t buy unless you get all manuals necessary to maintain the machine – this is required by law. Training can be provided by them or by RSTI.

Q What else would you like to add or do you think is important for biomeds to know about X-ray?

Yester: High-frequency generators are very good and widely available in all systems and provide very stable output. In general, outside of the digital detectors, X-ray systems have become very stable and last for a long time. Digital detectors and wireless detectors are becoming more widely used and have changed the workflow.

Monro: Prepare to have the smallest number of resources available to you than ever before. At the same time, get ready for more patients coming through than ever before. Make that equation work for you and your facility with a smile, and you will be exhausted every day, while knowing that you made a difference.

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