DOTmed Industry Sector Report: CR vs. DR

April 15, 2009
by Keith Loria, Reporter
This report originally appeared in the March 2009 issue of DOTmed Business News

Digital technology is quickly becoming the norm when it comes to X-ray departments at hospitals and other medical imaging facilities, as most are turning either to computed radiography (CR), direct digital radiography (DR) or a combination of both as they transition themselves from an analog to digital environment.

Imaging centers are finding that by going digital they are improving efficiency, reducing costs, and improving safety, yet there are differences of opinion on whether CR or DR is the correct choice.

"People don’t really understand the technology enough and a lot of radiology departments don’t understand the differences between what one company can do over another," says Anne Ji, Supervisor, Marketing Medical Systems for Canon U.S.A., Inc. "It’s hard to understand what is best for the facility. Every company will go in and say theirs is best, but how do they know? Education on this needs to be addressed and it’s something that every imaging facility needs to be paying close attention to."

Many of the smaller hospitals and imaging centers prefer to go with CR, which is attractive to them because of its portability and lower ticket price compared to DR. Another big factor is that in purchasing a CR, it eliminates the cost of renovating the X-ray room or retrofitting the equipment.

The best arguments in favor of DR technology are that it facilitates higher patient throughput and provides better image quality. Those are the key reasons why many of the larger hospitals have been installing DR systems into their emergency rooms.

"It’s convenience and flexibility vs. speed and quality," says Scott Burkhart, vice president, X-ray, North America for Philips Healthcare. "Right now when you go to an electronic format, it’s about workflow, it’s about speed. There is not another investment in the hospital today that offers that kind of return on investment in terms of efficiency. It’s become a slam dunk and everyone understands that."

Yet when looking at the advancements made in both technologies over the last few years, both CR and DR continued to make significant improvements and the line of demarcation between the two is starting to blur.

"The lines are blurred a lot. You can’t think of it simply as CR vs. DR anymore. CR is becoming more DR like and DR is becoming more CR like in many instances," says J. Anthony Seibert, an expert in digital radiology who works at the UC Davis Medical Center.

Fujifilm was the pioneer of CR back in the early 1980s and were first to market. When DR came along about a decade ago, there was some concern that the technology would eventually eliminate CR, but they have witnessed both technologies staying strong. Not only hasn’t CR fallen by the wayside, but improvements in CR’s design have in fact made it more competitive with DR.

"There’s no question that when DR started to become more popular and came down to a price point that could be afforded by the community hospital, CR became more competitive as well," says Penny Maier, Fujifilm’s Director of Marketing, Imaging Systems. "One of the nice advantages that DR originally brought to the table was improvements in image quality. CR responded with improvements in image quality to really put it on par. I think the end user can certainly benefit from those advantages. Just like any new technology after it has been sold for a few years, DR is no different, but CR is no different. We have seen the price start to decline for both."

"Wind back the clock 10 years and I thought CR was dead in the water, but I was wrong and it’s going to stay around for years to come," Seibert says. "The reason why is that it is portable, has multiple detectors, is pretty immune to damage. If you damage a DR system, you’re going to be out $80,000. I think from that perspective, CR as a drop in for conventional film radiology will be in for a while. It’s a really nice transition to a truly integrated digital radiography department."

The Facts of DR

It’s very likely that the debate over CR vs. DR will continue over the next decade and beyond but it’s important that imaging departments have a thorough understanding of the technology behind the process, their advantages and disadvantages of each and the bottom line costs of delivering the quality and efficiency they seek.

"I think we are going to continue to see a mixture of both cassette-based and cassette-less imaging," says Darren Werner, Marketing Manager Digital Products for Konica Minolta Medical Imaging. "I think a desire for portable imaging cassette will remain because of flexibility of use. I think examples of that are already coming into the marketplace."

Historically, DR, or digital radiography, refers to flat-panel-based digital X-ray systems that utilize either a direct or indirect conversion of X-ray energy to electronic signals. CR, or computed radiography, refers to cassette-based, photo-stimulatable, phosphor digital X-ray systems. Although most CR systems are cassette-based integrated systems, both upright and table configurations are also available. CR’s ability to utilize existing X-ray rooms while delivering high-quality images and efficient workflow will continue to make it a favorite in the digital X-ray market.

Typically, DR is believed capable of yielding higher detective quantum efficiency than CR, thereby offering higher image quality. With the integrated detector system, it also removes the cassette processing step within workflow.

Ji says the true advantage of DR technology is within the workflow. "With DR you have the images three seconds later," she says. "Then there’s the added benefit of the technician not having to leave the patient in the room to check images, which is good for safety reasons."

In the beginning, DR was hampered by its inability to handle cross-table or portable exams, but that is changing as portable and wireless DR systems are being introduced to the market.

DR systems have become more flexible. Canon introduced the first portable DR in 2001 and now detectors can be mounted on movable columns that can be positioned in three dimensions.

"With our portable technology, it’s about patient comfort. It’s the most similar you can find to CR and analog because you are still working with a flat piece of digital equipment not fixed into a system," says Ji. "You don’t have to wait for processing time."

Yet most experts maintain that no DR system is flexible enough to handle all types of clinical applications. And although the cost of flat-panel-based digital X-ray systems has come down considerably with newer, lower-cost systems, DR still carries a higher price tag than CR.

"When you’re dealing with a DR room, you’re going to get a higher assessment for certain," Maier says. "You really want to purchase a DR room where you will get a return on that investment. It’s fast and it’s going to be ideal for those types of procedures where you can move patients in really quickly and take advantage of the speed. Initially, a dedicated chest room, where patients might have chest exams would be a place where a DR room makes a lot of sense."

Some argue that the productivity gains from DR can offset its higher cost.

"Obviously, if you just look at the work flow aspect, volume is necessary to drive return on X-ray equipment," says Dave Widmann, Global General Manager-Rad/R&F for GE Healthcare. "Technologists no longer have to handle this cassette and move it around. DR gives you instantaneous images within 2-3 seconds of taking the shot. You see the image come up on the screen. Retakes go away. You don’t have to bring the patient back in."

With CR, you might have the patient off the table before you realize you didn’t get the shot you wanted, which Widmann says makes CR an obsolete technology.

"CR cassettes leave you very little opportunity to use digital data in different ways for further diagnosis," he adds. "With DR technologies, we can manipulate data we got through dual energy subtraction."

For those choosing to go all DR, they may have to face the issue of reliability. If you have two or three CR readers, you have automatic redundancy because you can just use another reader if something goes wrong. But if the DR detector fails, that room is closed off and you have to wait until service comes before using again.

"The concern of DR has always been expense and a lot of money is invested in one plate and if anything would happen to that room, which could see 60-120 patients a day – that will cause big scheduling and admission issues at the hospital. You need it to be working all the time," says Burkhart.

Case for CR

For a facility implementing digital technology for the first time, many may opt for a cassette-based digital X-ray solution because of the lower cost. This alone will vastly improve the workflow over the current film-screen process with a minimum financial investment while preserving existing X-ray equipment. CR still offers excellent speed and workflow to help boost technologist and radiologist efficiency, as well as flexibility in the unit placement within the facility for optimal utilization.

"The advantage of CR is that it’s very much like film in that it’s very flexible and very mobile and a wireless technology so to speak," says Burkhart. "It’s cheap in terms of an initial investment and highly flexible. The disadvantages are the image quality isn’t as good as DR and it’s not nearly as fast. You don’t get the productivity you get out of a DR system."

CR Readers can be used in conjunction with general X-ray equipment already in place, which makes them also in demand. Storage Phosphor IPs replace X-ray film so that remote equipment can still be utilized. CR Readers are durable, can be centrally located for increased access and can cover a broad range of applications.

Perhaps their greatest asset is that they can be positioned anywhere without stringing data and power cords around the patient.

"The great advantage of having cassettes is that it gives you flexibility to have any type of exam," says Maier. "That’s important in a trauma area, for example, where you need to be able to put a cassette under a patient that can’t be moved. It’s important in an OR when you need to do a cross table lateral. When you have to shoot across the table, a traditional DR will not allow that flexibility. A CR cassette really gives you the maximum amount of flexibility for any of these types of exams."

There are others who feel there is a big benefit in utilizing CR. Florida Hospital Celebration Health recently installed a new CR system and they have been enjoying the productivity that it has brought.

"I’ve always believed that if you set up your systems appropriately and productively. DR is not that much more productive than CR," says Sally Grady, Director of Imaging Services for the hospital. "With this new generation of CR, I believe that holds even more true."

Teaming Up

Hospitals will always need flexibility in a radiology suite because not every shot is the same-people come in on wheelchairs or on stretchers, some can’t stand, some are geriatric-and that’s why a combination of CR and DR is so important.

"I would by far recommend to the majority of our customers a combination of both," Maier says. "There are really different needs that DR will address better and physical needs that a CR system will address best. No one solution will be the ideal so we recommend to our customers that the combination is the best way to go."

Philips also believes that a choice doesn’t need to be made and is a big proponent of a combination system that utilizes both CR and DR technology.

"We have CR and DR and a combination where we have integrated the two modalities we call CRDR so no matter what combination of imaging fits your needs, we have an integrated solution that allows productivity to be maximized," Burkhart says. "We’ve found and been surprised that the combination also offers a significant advantage so the operators don’t have to go from one mode to the other, it’s all done on one console. It goes faster and is easier for them."

Both technologies coexist because each still has its distinct advantages, and which is best for a hospital or imaging facility depends largely on its size, workload, and infrastructure.

"When technologies first came on the scene they tried to divorce themselves from each other and differentiate and now as the markets have matured, the end user is looking for both cassette-based and cassette-less imaging," Werner says. "Nowadays the difference between CR and DR is hard to discern. If you are not intimately familiar with what’s inside the cassette, you would be hard-pressed to know the difference."

Money Matters

Obviously, as mentioned previously, the biggest advantage of CR over DR is the cost. One of the biggest challenges of investing in a DR system is having the appropriate infrastructure to install it. In many cases, an existing room has to be renovated to accommodate a new system.

DR typically requires purchasing entirely new X-ray equipment, and new X-ray equipment almost always requires remodeling of the radiography room, which can add anywhere from $50,000 to $200,000 to the project, depending on the existing infrastructure, regulatory requirements, and back-up clinical needs during the remodel.

Because of the equipment and infrastructure requirements, a DR system can be three to five times the cost of CR. The list price on a high-quality CR system today can be as low as in the $60,000 range, while for DR, you’re typically looking at $350,000-plus with the new equipment.

Stephen Spearing, Administrative Director of Imaging Services at Lewistown Hospital in Pennsylvania did an extensive evaluation of CR and DR before deciding on DR for mammography and CR for their other imaging needs. He cites cost as being the major factor.

"We are a small rural hospital of 139 beds so to get into DR you need to buy a piece of equipment for each room, and that’s roughly $300,000 per unit, 6-7 rooms, so you’re looking at nearly $2.1 million," he says. "It didn’t cost that to put CR in. It was a financial decision and strategy. If we had all the money we wanted, we would go with DR everywhere but that’s not the real world. We looked at how to do it effectively, quality wise and cost efficient and that’s what we did."

Economic Uncertainty

Burkhart explains that after first coming into the market, CR grew to $500 million in volume but with many users converting to DR over the years, especially as it has gotten cheaper, that number is gradually decreasing.

"We see the market going down 5% to 10% a year," Burkhart says. "It’s hanging in there very well given the significant advantages of DR but it’s still a very substantial part of the market and probably will be for some time. In terms of unit sales, we’re seeing 60% DR, 40% CR. If you want to talk about patients, it’s probably about 70% DR and 30% CR."

There has been a bit of a slowdown within the industry as many hospitals and health facilities are contemplating if this economic climate is really the best time to invest in new equipment to go digital.

Because of that, Ji says Cannon has thrown their energy behind upgrades and retrofits, which will not cost as much as a new system.

"About half of our business is dedicated to upgrades and retrofits. A lot of manufacturers are coming up with that now because of the way technology is going," she says. "We hear ‘we don’t have money for DR because of the way the economy is going’ but we are able to work with them and help them with the upgrade."

Burkhart sees some hospitals wrestling with the idea postponing their buying as they wait out the economic crisis.

"We’re seeing a lot of hospitals converting their entire X-ray operation over to DR. With economic troubles, a dilemma for administrators is it’s expensive to do but they can get their money back in a year or year and a half. There’s so much benefit from operation efficiency, there’s a chance to do more with less, and probably the best place to put your money. Those who want to create as much efficiency, there is probably not a better investment in medial technology than to go from manual process to a more automated process. We have studies that show exams decreased from 12 to 15 minutes to 2 to 3 minutes. That’s a dramatic impact."

Down the Road

Both CR and DR have come a long way since their inceptions, and its expected that they will continue to make advancements quickly.

"If you think about the opportunities with the digital image and the technology we harnessed with digital imaging, the future is wide open," says Widmann. "I always advise customers that DR is a very strong value proposition just based on going filmless and improvements to workflow. Beyond that, what a customer should really look at is the future of digital and how the system can be leveraged. Are they buying systems that will have capabilities to do what they want in the future?"

A gander at the digital radiography enhancements and offerings at RSNA this past November show that most of the major players in the field are ready to continue the trend. Many of the companies were debuting game-changing technologies, such as wireless digital detectors designed to increase the flexibility of digital studies and enhancements for full-field digital mammography and hardware modifications that make the units more bariatric-friendly.

New lightweight designs are also contributing to the new era of portable DR systems. Whether it is an adjustable cord for room-to-room installations or wireless, these recent introductions attest to the fact that DR is moving toward portability.

"That’s what’s most exciting about the imaging business, watching what’s coming down the pipeline and watching the technology really advance further," says Maier.