Transitioning to Digital Radiography

Clinical, Financial and Operational Considerations

Presented By

Lori Webb, R.T. (R)Clinical Analyst, MD Buyline

Katie Regan, M.A.Clinical Publications Manager, MD Buyline

• Joined MD Buyline in 2008• 20 years experience in the clinical healthcare field • Practicing clinician at a local freestanding ER• Registered Radiology Technologist, American

Registry of Radiology Technologists

• Joined MD Buyline in 2012• Seven years of clinical and research experience • Responsible for clinical, financial and general

healthcare publishing projects at MD Buyline • Member of Healthcare Finance Management

Association

The Digital Age

• The medical imaging market is expected

to reach over $35 billion by 2019– The global digital radiology market is

forecasted to pass $13 billion by 2018

• Medical imaging moved away from

analog technology toward digital

solutions – Flat-panel detectors (FPDs) offer better image

quality, faster processing time and greater

dose reduction over analog predecessors

“Studies have shown that implementation of PACS, EHR and digital imaging shorten

turnaround times and increase medical imaging

department volume without a subsequent staffing increase.”

Health Care Industry Advisory Council 2013 (HCIAC)

The Shift from Analog to Digital• First implemented in cardiology

and mammography due to clinical improvements – Workflow efficiency– Image quality– Lower radiation dose potential

• General radiography units transitioned last due to the volume of equipment and presence of computed radiography (CR) systems– CR allowed images to be digitized– Acted as a bridge into the digital age

for general radiography

X-ray film used for imaging, must be developed

Imaging plate is used and digitized by optical scanner

Digital image acquired by direct or indirect flat panel detector (FPD)

Analog

Computed Radiography

Digital Radiography

Digital Cardiology• Conversion of cardiac imaging to digital flat-panel detectors (FPDs) was

driven by several considerable advantages – Faster patient turnaround time and higher productivity– Ability to record dynamic and static X-ray images at a high-image quality– Faster acquisition of images and greater flexibility with post processing of the

images– Better contrast and spatial resolution that allows greater visualization of small

guide wires, markers and stents– Lower radiation dose to patients and staff

Evolution of Digital Mammography• Full field digital mammography

(flat-panel detectors) offer– Lower radiation dose to patients– Greater image quality– Shorter exam times– Broader dynamic range– Digital CAD– Breast tomosynthesis

• Clinical improvement and its effect on public opinion have made the move necessary for providers to stay competitive

• Initial capital investment for digital mammography is substantial

• Most facilities are 100% digital(DR or CR mammography)

System Average Purchase Price

Service Contract

Analog $80,000 to $140,000 $7,000

Digital $210,000 to $450,000

$25,000 to $48,000

Digital Mammography

• Breast cancer prevention, detection and treatment is highly profiled – Compelling clinical results have left patients demanding and expecting digital

mammography • Digital Mammographic Imaging Screening Trial (DMIST) established benefits of

digital mammography over film-screen, particularly for women younger than age 50 with dense breasts

• FPD offers shorter exam times and the ability to increase throughput

• As hospitals compete for patients, volume is a key factor to the successof any service line

Clinical and Patient Drivers

System Patient Volume Exam Length

Analog 3 to 4 per hour 15 to 20 minutes per exam

Digital ~6 per hour 10 minutes per exam

Digital Mammography

Financial• Separate reimbursement levels

for mammography– Analog system exams: $81.66

(CPT 77057 bilateral screening)– Digital system exams: $138.81

(HCPCS G0202 screening)

Legal• The “digital divide” is when a

facility offers both digital and analog mammography– Creates patient, legal and

productivity issues

Financial and Legal Considerations

Evolution of Digital General Radiology

X-RAY 51.72%

NUCLEAR MEDICINE

4.28%

OTHER X-RAY 12.5%

ULTRASOUND14.26%

MR 4.99%

CT 12.02%PET 0.23%

Source: Frost & Sullivan, 2004, #A630-50, 1-7

• General radiology exams are the “bread and butter” of medical imaging– 74% of general radiologic exams, such as

X-ray and radiography/fluoroscopy (R/F)– The volume of R/F studies skyrocketed

from 25 million in 1950 to 293 million in 2006*

• The focus on converting general radiology to digital, FPD technology increased due to– The need to bring all equipment to digital

standards for communication with PACS and EMRs– The availability of budgetary dollars for technology upgrades– The need for a more efficient workflow, better image quality and lower radiation dose

*Source = American Society of Radiologic Technologists

Digital General Radiology Cost• Pricing associated with digital systems is complicated by the number of

possible system combinations and the “digital retrofit” upgrade path System Price Range

Fixed X-rays

Analog • $50,000 to $125,000 • Additional cost of $33,000 to $85,000 for a CR system

Retrofit • $100,000 to $150,000

Digital• $165,000 to $550,000 • Low-end price for a single-panel system • Higher price for a dual-detector system that is capable of advanced applications

Portable X-ray

Retrofit • $100,000 to $130,000

Digital • $150,000 to $200,000

R/F

Image Intensifier • $325,000 to $425,000

Digital • $500,000 to $800,000

Digital Retrofit Costs

• A “digital retrofit” upgrade path allows facilities to use an existing analog fixed X-ray or a mobile system with an FPD

• Retrofitting an older unit is considerably less costly than investing in a new digital system

• Pricing for retrofit FPDs

Vendor Size of Detector Plates Cost of Detector Plates1 14” x 17” Cesium Iodide $80,000 - $100,0002 14” x 17” Cesium Iodide $92,000 - $106,000

3 • 14” x 17” Gadolinium• 14” x 17” Cesium Iodide

• $65,000 - $94,000• $87,000 - $104,000

4 14” x 17” Cesium Iodide $76,000 - $87,000

X-ray and R/F

Digital RetrofitBridging the Gap Between Analog and Digital

2012 2013 2014 2015 2016 20170%

5%

10%

15%

20%

25%

IHS Forecast: Global Market for General Radiography X-ray Equipment

Mobile Retrofit Other GR X-ray Equipment

(Revenue Growth Profile)

R/F: Image Intensifier vs. FPD

• Price point advantage• Technology is still considered

viable• Better spatial resolution

Dynamic FPD: Pros• Smaller size• Easier to position• Sleek system appearance• Less geometric distortion and

glare• Less degradation of image quality

from flare or veiling

Image Intensifier: Pros

R/F: Image Intensifier vs. FPD

• Larger size• Harder to maneuver/position

for exams• Limitations in dynamic range• More glare and geometric

distortion

Dynamic FPD: Cons• Higher cost• Less spatial resolution

Image Intensifier: Cons

Evolution of Digital Mobile C-arms• Cost of mobile c-arms

• Digital, FPD mobile c-arms offer improved clinical performance and workflow over image intensifier systems – Improved image quality– Reduced dose– Extended dynamic range– Reduced distortion and image clarity for anatomical areas of interest

System Capital Price Range Service Contract Price Range

Image Intensifier-based Mobile C-arm $165,000 to $226,000 $8,400 to $10,200

Digital, FPD-based Mobile C-arm $260,000 to $399,000 $13,500 to $15,580

X-ray System Configurations and Pricing

• High-volume exam setting ($225,000 to $600,000)– Triple-Detector

• Uncommon• Pricey • Highly efficient• Has a fixed-wall FPD, fixed-table

FPD and wireless, portable FPD– Dual-Detector

• Involves a fixed-wall FPD and separate portable, wireless FPDs

A dual-detector in the form of two portable, wireless detectors

X-ray System Configurations and Pricing

• Medium to low volume ($150,000 to $275,000)– Single-Detector

• A single wireless, portable FPD that can be moved from wall stand to table and can be used for table-top exams

• Very cost effective and the most common configuration

A single-detector configuration or analog that can be retrofitted

X-ray System Configurations and Pricing

• Retrofit upgrade ($106,000 to $140,000)– One or two wireless FPDs are retrofitted using

an existing X-ray tube, wall stand and table– Retrofit panels can be mixed to some degree

with other vendors’ X-ray systems

• Small FPD panels ($62,000 to $85,000)– Used to retrofit analog systems or with new

fixed/portable X-ray system– Used in NICUs, pediatric wards, children’s

hospitals and for orthopedic exams– Appropriate for imaging smaller anatomy

Previous generation analog portable retrofitted with an FPD

Sole Sourcing vs. Mixing Vendors

Sole Source: Pros• Bundle systems together for

optimal pricing on purchase and service/support

• User interfaces/operating systems are uniform across modalities, decreasing learning curve

• Panel sharing

Mixed Vendors: Pros• Ability to customize and tailor

solution for workflow• Greater negotiation power

Sole Sourcing vs. Mixing Vendors

Sole Source: Cons• Vendor complacency• Loss of negotiation leverage• Risk of missing new or innovate

technology or features• Chosen vendor may not have the

top product in every category• Panel sharing

Mixed Vendors: Cons• Issues related to learning and

operating multiple vendor’s user interfaces is decreasing

• Loss of leverage in bundling support

Service Cost

• Increased cost of ownership when moving from analog to digital

• Facilities often elect for more full-service agreements due to– Complexity associated with supporting digital systems

– Lack of digitally-trained biomedical engineer (BME) staff

– “Software keys” required to diagnose and repair equipment

System Service Price Range

Analog $8,000 to $12,000

Digital $30,000 to $55,000

Service Cost• FPDs are moderately fragile and expensive• FPDs are portable and at a greater risk of being damaged• Many manufacturers offer or require separate service coverage for the

panel known as “drop-panel” coverage– Deductible per occurrence ($5,000)– Additional annual premium – Vendors may require sites that wave drop-panel coverage to sign a waiver

• Replacing the FPD will be market value ($80,000 to $125,000)

Service Recommendations• Suggestions for coverage hours

– Facilities with multiple systems: Monday through Friday from 8 a.m. to 5 p.m. – High-volume settings/dedicated ER X-ray rooms: Monday through Friday from

8 a.m. to 9 p.m. (extended coverage)

• When determining coverage amount– Consider the service history of existing systems in your facility– Assess how critical equipment is to your workflow and backup system

availability

• Service coverage for retrofitted systems– Typically service contracts are already in place for existing analog systems– Retrofit panel vendors should offer coverage and drop/damage protection

Service Recommendations• Types of coverage

– In-House or BME• Original Equipment Manufacturers (OEMs) offer biomedical training classes on

digital X-ray and R/F systems • Switching to an in-house service will depend on biomedical staff’s level of expertise• First-call agreement is a viable savings opportunity• Vendors do not always provide seamless access to proprietary “software keys”

– Third-Party Vendors• High-risk review on a case-by-case basis• Parts availability and replacement detectors can be difficult for third-party vendors

to obtain• Often unable to provide loaner panels as readily as OEMs

Clinical Considerations of “Going Digital”

• Clinical advantages of FPDs – Higher image quality– Less distortion– Potential for dose reduction– Greater anatomical coverage area– Immediate view of the image – Additional advantages for R/F systems

• Better penetration of anatomy • Additional room within the unit for

patient positioning and movement

Financial Considerations and Soft Dollar Benefits

• Financial considerations– “Going digital” requires a substantial investment by providers– Currently no separate reimbursement for digital and analog exams– Film and film processing costs are eliminated

• Measureable soft dollar benefits of switching to digital– Increased workflow efficiencies and time savings

• Immediate image preview and availability– Increased room utilization– Better turnaround times and increased patient satisfaction

• Increased patient safety and “touch” time– Maintaining the competitive edge

• Referring physicians are more likely to recommend or refer to hospitals

Increased Workflow Efficiencies and Time Savings

• Increased workflow efficiencies– A digital room can take the place of two or

more analog rooms– Some systems allow radiology administrators

to track usage and workflow performance of different users• Determine which technologists are the most

efficient and identify problem areas

• Time savings– View images immediately equates to saving

10 minutes per patient– Reduce the average report turnaround time – Allow radiologists/physicians immediate

access to images wirelessly

Maintaining a Competitive Edge• An informed patient

– The information age is changing how patients seek out care • Patients are becoming

increasingly well informed about the advantages of digital systems

– Hospitals are increasingly faced with the challenge of competing for patients

• Digital technology creates confidence for referring physicians• Gaining more referrals, in areas where multiple hospitals are competing for the

same patients is difficult

Prioritizing the Digital Transition• High-volume areas, such as the ER, are converted first

– The largest impact comes from improved turnaround times – Items to consider when prioritizing

• What are patient volumes, types and programs?• Which rooms do you use for outpatient referrals? • Which room(s) are used for inpatient routine exam traffic? • Do you have areas in your department that are not centralized that needs workflow

efficiency improvement?

• Mobile c-arms, lower volume rad rooms and R/F rooms are converted last• Fleet management and inventory review

– Move early, digital generation systems to facilities and clinics with lower exam volumes – Review inventory with clinical engineering or BME departments

• Age of CR and analog systems• Repair histories: replace the oldest and problem units first

When and Where Analog Is Still Appropriate

• CR is still appropriate in low-volume exam scenarios – CR has longer processing and exam times for patients

• When to go digital in general radiography?– All in or one at a time are both viable approaches– Concerns associated with handling conversions one at a time

• Continuity in technology for staff and physicians• Questions over discrepancies in image quality for analog vs. digital

– End of life decisions• Easier to purchase digital systems during end of life scenarios

The Cost of “Going Digital”• General radiology can have a significant impact on patient volumes and

the bottom line• Clinical and soft dollar benefits can offset the financial investment of

“going digital”– Clinical advantages: higher image quality, less distortion, greater anatomical

coverage area and potential for dose reduction– Soft dollar benefits: increased workflow efficiencies and patient satisfaction

along with time savings

Questions and Answers