For this month’s roundtable article on radiography, several original equipment manufacturers (OEM) were able to share insights, as well as a third-party service provider. Those participating in the discussion are Rob Fabrizio, director of strategic marketing, digital radiography and women’s health, FUJIFILM Medical Systems U.S.A. Inc.; Mark Lothert, MD, head of product management, service business management, Siemens Healthineers; Steve Romocki, worldwide product line manager for radiology systems, Carestream Health; Jason Schneck, president and general manager imaging, U.S. and Canada, GE Healthcare; and Medical Equipment Doctor Operations Manager Tara Stack.
Fabrizio: Medical imaging vendors today are increasingly innovating digital radiography (DR) equipment to maximize workflow efficiency, provide exceptional image quality at low dose for patient safety and improve patient experiences. Facilities looking to purchase new X-ray equipment should be considering all of these factors to ensure they are driving more accurate diagnosis and better, safer patient outcomes. Today, Fujifilm’s DR detectors are engineered with patented Irradiated Side Sampling (ISS) technology and noise reduction circuitry to reduce noise in ultra-low dose images to improve image quality and detail. The two technologies combined complement each other to perform better with low dose and low penetration exams from the smallest to the largest of patients and anatomy. Additionally, image processing technologies push dose efficiency even further, like Fujifilm’s Virtual Grid and Dynamic Visualization, also help produce exceptional image quality for all types of images acquired at lower and lower doses. It’s also important that the detectors are as lightweight as possible for easier and safer positioning for technologists and higher durability. Detectors with tapered edges and smooth surfaces help technologists more easily slide them under the patient. Also important, especially in this day and age, is that they come equipped with antibacterial coating for additional patient safety in infection controls.
Lothert: Increasingly, automated positioning features that first appeared on premium radiography systems are migrating to mid-tier and value-tier systems. The reason: Health care providers are being asked to do more with less staff, and equipment automation is one way to do that. Also, more 2D and 3D cameras are being incorporated into the tube head. And since artificial intelligence (AI)-based features use these cameras routinely, facilities must ensure that these cameras function optimally.
Romocki: There has been tremendous progress in improving and automating workflow to increase productivity and image consistency. Carestream offers new AI-based smart features for our DR rooms that help optimize workflow for radiographers and increase efficiency; and help improve image consistency, patient communication and reduce retakes. DR detector technology also is evolving. Our new Lux 35 Detector is glass-free and lighter weight: weighing around 5 pounds. Its lighter and more ergonomic design makes it easier for radiographers to transport while making rounds and performing bedside exams and is more comfortable for patients.
Schneck: Many of the newest features across radiography equipment are digital enabled applications and AI embedded into the systems that help standardize and improve clinical workflow. Faster and more consistent imaging that increase the effectiveness of clinical decisions and patient experience across the enterprise.
Stack: The goal of medical device technology should always be patient safety driven, especially with radiography equipment. Radiography devices that provide the lowest radiation exposure without compromising image quality should be a priority when considering the purchase of new equipment. Imaging devices that help manage radiation dose can help facilities protect their patients and could provide a competitive edge compared to other health care organizations. Other factors to consider are the overall image quality, speed and efficiency of the equipment, and ease of use for the technicians. I have seen facilities spend a lot of money on radiography equipment that was never put into service because the staff could not figure out or didn’t feel comfortable using the new equipment. The last area to consider before purchasing new equipment is the post service costs and available support after the warranty expires. How much is an annual service contract? Are the parts proprietary to the manufacturer or are parts like the X-ray tube available on a third-party market? Does the manufacturer provide service training and offer a variety of service agreement levels that include co-op agreements? Can a third-party company support the device?
Fabrizio: DR may be more affordable than one would think. There is a ton of competition in the DR space today, which has helped make it more affordable compared to when they first came to the market. There are plenty of cost-savings benefits that come with new DR. For instance, workflow is faster and detectors are easily shareable so you can do more with less. Another consideration is that many systems such as new RF rooms, C-arms and CT systems, for example, are being designed for multipurpose uses to expand capabilities and maximize return on your investment.
Lothert: Facilities should clearly identify the standard features they require in any radiography system to satisfy their unique needs. Reducing optional features will lower total system costs.
Romocki: Facilities should look for scalable, upgradeable rooms – like our budget-friendly DRX-Compass, that will meet their changing needs. The DRX-Compass offers a bridge for health care facilities looking to move from an analog or retrofitted X-ray room to a digital system, and now includes a floor-mount option for sites that are unable to accommodate an overhead tube crane. Shareable detectors can be shared with any DRX equipment allowing facilities to share and move detectors to where they are needed most. Additionally, lower-cost detectors provide an affordable way to upgrade to wireless digital imaging.
Schneck: There are many new acquisition models that are emerging across the industry to address budget constraints that exist. Software purchased as a subscription model is helping reduce upfront acquisition costs while ensuring technology stays up to date with the most current software applications throughout its life cycle. Some providers are also moving toward managed equipment relationships that spread out capital expenditures over long term relationships with a commitment to keep technology current through upgrades and agreed-upon replacement schedules.
Stack: Radiography devices should be profit centers for health care organizations. When you are planning to acquire a new radiological device, a business plan – including the expected ROI – should be established. The business plan should include answers to questions like: Will this device increase the volume of patients daily? Does the new device/technology improve patient outcomes and patient experiences? What is the insurance reimbursement for the procedures that can be performed on this device? Can the facility establish a new clinical program that will give the organization a competitive advantage over competitors? Another area to consider for budget constraints are units on the third-party market that are completely refurbished and still able to be serviced and supported. Some third-party organizations provide leasing options that can work in your advantage while your clinical program is being established.
Fabrizio: It’s important that providers look to purchase equipment from a trusted vendor with an excellent reputation first and foremost in reliability, and then in service as well. Reliable equipment costs less to maintain and OEM service contracts have become more affordable. FUJIFILM Medical Systems U.S.A. Inc. takes service seriously, our service and applications personnel, our parts division and our Technical Assistance Center (TAC) have achieved certification under the prestigious Service Capability & Performance (SCP) Standards program. SCP Standards quantify the effectiveness of customer service and support and represent best practices in the industry. Every day we strive to deliver world-class customer service and support, and passing the rigorous requirements necessary to achieve SCP Certification is confirmation that we are succeeding in this mission and achieving high levels of customer satisfaction. It’s also important that a radiology service provider is a one-stop shop for its customers. For instance, our service and our customer’s biomed engineers are factory trained side by side. We stock the most common spare parts and our parts are available for fast overnight shipping. We also offer Active Line Remote Services, a system that is designed to monitor and anticipate system malfunctions before they happen. This valuable functionality can help prevent downtimes, in-person service visits and simplify visits when they are needed by helping identify needed parts before a service engineer is dispatched.
Lothert: The one-size-fits-all services contract doesn’t always work; facilities should look for flexible service options. An imaging system’s criticality with respect to the entire fleet as well as its hours of operation, redundancy level and clinical use influence the choice of service contract. Also, the service provider should offer continuously trained OEM service engineers and ample geographical coverage, as well as be able to escalate issues beyond a 1-800 number. The facility should have access to value-added services such as asset management solutions (for example, system performance information), with potential integration into a hospital’s computer maintenance management system. And lastly, the service provider should offer multiple methods of educating technologists.
Romocki: Look for a supplier that has a robust portfolio of products to choose from and a comprehensive roadmap to bring new capabilities to the market, including the ability to leverage future applications like artificial intelligence. Also ask about standardization of software and equipment. Often, radiologic technologists move among different pieces of equipment within a facility or network of facilities. Having a consistent user interface for mobile and/or room-based imaging systems not only reduces the training required, but also enhances productivity and ease of use. Lastly, ask about their applications training that can help you optimize your use of the product’s features; and service options to keep your equipment running smoothly.
Schneck: Depth of resources and capabilities are important when choosing a service partner to ensure any equipment downtime is minimized. Also consider the ability to do remote diagnosis and service of issues. The ability to predict equipment failures and resolve issues by remotely monitoring equipment performance enables a service provider to resolve an issue and prevent a hard-down emergency service event before it occurs.
Stack: X-ray service providers should be partners and they must provide more than just maintenance and repair. A significant part of providing service is consulting and helping health care organizations with important factors like ACR accreditation. Without ACR accreditation, which proves you have a quality radiology department, your organization will not receive Medicare reimbursement. A service provider should offer programs that will help your organization obtain the maximum profit and provide the best patient care possible from the imaging devices. That includes up-time, parts availability, remote diagnostics, reliable on-site service, regulatory compliance and assistance with accreditation.
Fabrizio: I highly recommend that providers look to purchase from vendors who offer simplified and consistent user interfaces across multiple imaging systems. Whether a provider purchases a DR portable, a retrofit to an existing room or complete X-ray room, the user interface should be the same. This allows for less upfront training and once technologists know how to use one system, they can easily move to the next with little to no training.
Lothert: The facility should not only make sure that continuous software-based updates and frequent upgrades are an integral part of their service engagement, but also that options and upgrades (for example, specific computer hardware upgrades) are available outside a contract’s parameters. And, since every system eventually reaches its limits from an upgradability perspective, the facility should ensure that the service provider offers attractive equipment replacement programs.
Romocki: The first step for facilities is to identify and incorporate growth scenarios into their long-term planning and design. Additionally, they need to develop projections for their service and uptime requirements based on their facility type, equipment utilization and degree of equipment redundancy. They also need to examine any shifting trends in the demographics and needs of their patient base. The foundation for a future-ready strategy emphasizes modular capital purchases and professional services to reduce risk, and to increase flexibility and adaptability to change.
Schneck: There are non-obsolescence offerings across the industry that provide for upgrades and updates as part of a contractual commitment. Upgrades can also be offered in parallel with ongoing service agreements or purchased independently. Certain software subscription models ensure operating systems and applications stay current throughout the life of the system.
Stack: Upon purchase of any X-ray device, the facility should determine if software upgrades can be purchased outside a service agreement and understand the associated costs. The life expectancy of the device is a factor with upgrades. How long will this device work before upgrades are needed? When examining the reliability of the device, one thing to consider is how many upgrades have been required since the device entered the market. How many were due to product recalls? Understanding these factors can help determine the reliability of the device and the need for a service agreement.
Fabrizio: A facility’s biomed should look for products that are reliable and easy for staff to use from vendors that are experienced with integrating with various other vendors’ equipment and enterprise systems. Last but not least, biomeds should look to vendors with consistently reliable equipment, quality training, 24/7 support and fast parts availability.
Lothert: Consider remote diagnostics and break/fix capabilities to support biomed efforts. Evaluate the ease of ordering OEM spare parts. Consider the quality of the OEM’s training capabilities and whether they offer an enterprise-level approach with a holistic plan to train biomeds beyond radiography. And finally, determine whether asset information can be integrated into the hospital computerized maintenance management system (CMMS).
Romocki: To facilitate future upgrades, radiography equipment should be scalable to meet a facility’s changing needs. Also, adopting AI-based product features/technology can help a facility accelerate transformation, while improving diagnoses and patient care.
Schneck: It is important to evaluate the total life cycle cost and clinical capability of the device when evaluating options. Serviceability, technical training and applications support should be important considerations to evaluate in addition to feedback from clinicians.
Stack: All medical device purchases should have a failure mode and effects analysis performed before committing to the purchase. How many recalls, adverse events, upgrades and safety alerts has the device had since it was made available on the market. What is the prediction of failure? From a cost perspective, is this unit available on the third-party market and are there parts available? What is the cost of the service agreement and is there technical training available? Can this unit be serviced on a third-party market at a reduced cost? Can a cost-effective service delivery plan be established? Are loaners available to minimize down time?
Fabrizio: In many cases, imaging acquisition workstations can be more isolated from threats by being configured on a closed network and limiting the data communicated. Nevertheless, these systems require all of the same requirements to protect data and access. Controls are built-in for encrypting drives, two-way handshake authentication for device communication, customizable authentications, secured login, auto logoff, audit controls, secure application of patches and updates, health data de-identification, backup and disaster recovery, physical locks and, of course, malware detection and protection.
Lothert: Any product with software components that is connected via a network or through data ports can be vulnerable. The best defense starts with educating users and involved parties as well as restricting user access. Network-based cybersecurity solutions with scanning capabilities and vulnerability assessments as well as product-based virus protection solutions should prevent malicious attacks, although no form of protection is 100 percent guaranteed.
Romocki: Cybersecurity is always a priority, and we strongly recommend that customers keep current with upgrades to software. Our ImageView software is built on Windows 10 which offers several cybersecurity advantages such as intrusion detection and prevention, two-factor authentication for secure login options and encrypted Data in Transit ( DIT) for network communication and Data at Rest (DAR) hard drive protection.
Schneck: The health care industry is one of the most impacted industries from a cybersecurity risk and threat perspective. The average cost of a data breach is now greater than $7 million. As technology in the health care domain continues to grow and more devices become smart-connected-networked devices, the threat of such risk is expected to increase. Radiography devices are not immune to this growing threat and, depending on a number of factors including age of a device, configuration, network topology and more, they can pose a potential cyber risk if they’re not proactively managed from a medical device cybersecurity perspective from the time of onboarding through the device life cycle.
Stack: There have been reports in the past about cyber intrusion from nuclear med cameras and IT departments not been factoring in their remote access. Any medical device that is integrated to a computing system, storing electronic health information or software that controls the functions of the device is at risk for cybersecurity issues. Keeping the operating systems updated with the newest vulnerability patch and developing plans to detect abnormal communication traffic between the hardware is a must. Including your radiography equipment in your cybersecurity plan is absolutely essential for the safety and security of your organization.
Fabrizio: Medical imaging facilities that are looking to purchase new radiology equipment and systems should consider partnering with vendors who are constantly innovating and expanding their product offerings and not just making “me too” products. Partners that focus on what’s important to patient safety, user workflow and accuracy.
Lothert: Some newer radiography systems don’t require the facility to perform a major “forklift upgrade” to acquire new features and functionality. The facility can simply add new features – such as AI-based collimation – on an as-needed basis as they become available, much like an app store.
Romocki: In addition to hardware, consider the role of software when choosing your X-ray room equipment. Image processing software is evolving considerably through the application of advanced algorithms and AI. So your choice of X-ray room equipment and DR detectors needs to support advanced software to take advantage of innovative imaging applications like options for smart noise cancellation, pneumothorax visualization, dual energy and digital tomosynthesis. Make sure the equipment you choose today can support future advances – otherwise your imaging equipment might become obsolete too quickly.
Schneck: The radiography equipment market is very dynamic with new digital and AI enabled software applications taking image quality, speed of exams, patient experience and clinical workflows to an entirely new level.
Stack: When radiography was first introduced to health care it was considered a miracle. The impact of a well-planned radiology department is crucial to the success and stability of your facility. It is important to understand the new technology available, and to develop care plans based on that technology. If you work in imaging or service imaging equipment and have not been to the RSNA convention, you should plan to experience it. New technology is always on display, and you can witness new miracles about to happen right before your very eyes.
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