Purchasing used x-ray equipment can be a dicey proposition. During times of budget constraint, it can be a viable option over the costly acquisition of new equipment however there is much homework that needs to be done on the buyer’s end or you may end up spending more money than you would have spent purchasing a new system, may incur a serious loss of revenue and may even end up with a worthless system that you have to pay someone to remove from your facility!
I have seen several “reputable” companies selling “refurbished” x-ray systems that are mixed systems of half of this model and half of that model and God only knows what is in between. These companies are masters of marketing, masters of high pressure sales but usually know less about the equipment than John Doe on the street except for some basic x-ray sales terminology. I witnessed one well known equipment refurbisher that sold my customer what was promoted as a G.E. Legacy R/F room. It had a G.E. Legacy Spot film device however that was the only component on the system that was from an actual G.E. Legacy system. Instead of receiving a high frequency G.E. Legacy system generator they ended up with an old G.E. Advantx mid to low frequency generator and an Image Intensifier that was 20 years old. Needless to say the image was horrible and months down the road the system was removed from the facility because the radiologists would not use it…..even though the seller insisted the image was fine and they got what they paid for!
Here are a few things to look for and demand when buying a pre-owned or refurbished R/F x-ray system.
1) System matching model numbers, serial numbers and date of manufacture across the board.
2) Age of Image Intensifier, camera/camera pick up tube and monitors. Remember, your image will only be as good as the weakest chain in the link!
3) Age and use/hours on both the fluoroscopic and radio-graphic x-ray tubes.
4) ALL prior service documentation to review before purchasing the system to see if it has been a lemon!
5) Demand an inspection of the system by a service provider you select and make sure it isn’t a service provider that does business with them. This is money well spent!
6) A detailed list of all components the seller has replaced…..most refurbished systems are nothing more than cleaned and painted systems….period.
7) Previous owner contact information.
Remember, an older Image Intensifier, camera system and x-ray tube means a diminished image and are costly to replace! If the seller cannot supply you with all of the information and requirements above I personally would walk away from the sale….no matter what they promise you or how great the deal sounds!
These checks will not guarantee you a system that is flaw free but will give you a general idea of what it is you are getting and covers the majority of big hit service items should the system need work. You can do the homework and legwork yourself or you can contact Rapid X-Ray and let us do it for you!
Will your x-ray reimbursement go down? Probably!
Awesome article from Auntminnie! Read on!
Medicare to cut analog x-ray payments starting in 2017
February 8, 2016 — As part of a push to nudge U.S. healthcare providers to adopt digital radiography (DR), the Medicare system will begin reducing payments for exams performed on analog x-ray systems starting in 2017. The year after that, sites using computed radiography (CR) equipment will also see payment reductions.
Medicare payments will be reduced by 20% for providers submitting claims for analog x-ray studies starting in 2017 under a provision in the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. Starting in 2018, payments for imaging studies performed on CR equipment would be reduced by 7% for the next five years, and 10% after that.
While the law’s provisions on analog x-ray are expected to have a minor impact due to the small number of traditional systems still in operation in the U.S., the reductions in CR payments could have a much broader effect: More than 8,000 CR units are still in service in the U.S. All of these systems must be replaced or imaging facilities will experience payment reductions.
Transforming the oldest modality
The adoption of DR over the past two decades has transformed medical imaging’s oldest modality, enabling bread-and-butter x-ray images to be acquired quickly and then easily transferred into PACS for distribution, interpretation, and archiving. Before DR arrived, many facilities upgraded their x-ray equipment with CR, which replaced film-screen cassettes with imaging plates that can be carried to a reader for digital output.
The provisions inserted into the Consolidated Appropriations Act are designed to speed the transition of U.S. healthcare providers toward digital radiography by changing the Hospital Outpatient Prospective Payment System. Classified as a “special rule,” it specifies a 20% cut starting in 2017 to the technical component of reimbursement for an x-ray taken using film.
The cuts for CR are phased in over time, starting in 2018. Payment for the technical component of an x-ray acquired using computed radiography will be reduced by 7% during the years 2018 to 2022 and by 10% after that. Complete text of the act can be viewed by clicking here.
Origins of the provision began about a year ago, when the American College of Radiology (ACR) began working with various manufacturers, in particular Varian Medical Systems, according to Cynthia Moran, ACR’s executive vice president of government relations, economics, and health policy.
While Varian is best known for radiation therapy systems, it also manufactures DR panels for inclusion into new OEM x-ray systems and offers DR retrofits for installed analog and CR x-ray systems in the field.
The DR provision was originally inserted into the 21st Century Cures Act, legislation proposed in 2015 that among other things would have repealed the Multiple Procedure Payment Reduction (MPPR). The controversial MPPR rule was implemented by the U.S. Centers for Medicare and Medicaid Services (CMS) in 2012 and reduced reimbursement by 25% for imaging studies performed on the same body part on the same patient in the same imaging session.
ACR worked with vendors, including Varian and the Medical Imaging and Technology Alliance (MITA), on getting the DR provision inserted into the Consolidated Appropriations Act in exchange for their support in reducing the MPPR cut, Moran said.
“They supported us in us trying to get MPPR payment reduction passed, and so we partnered with them to go to Congress to see if they would do the two imaging provisions and handle them at one time,” Moran said.
While it’s tough getting any proposed legislation through Congress, Moran said the two provisions were attractive because they will save the federal government $350 million over the next 10 years. In the case of the DR provision, the savings will come from lower Medicare payments being made to hospitals operating analog and CR equipment.
How much will the legislation affect U.S. hospitals? Not much when it comes to analog x-ray, as the number of film-based systems operating in the U.S. has fallen to miniscule levels, according to market research firm IMV Medical Information Division.
In its 2013 x-ray market report, IMV projected that fixed analog general x-ray rooms made up just 1% of the installed base at U.S. hospitals, down from 5% in 2010. Indeed, the decline in the analog installed base was so great that in its 2015 report IMV didn’t bother to ask radiology administrators how many analog units they were still operating, according to IMV Senior Director Lorna Young.
“So few people have film that it’s not worth talking about,” Young said. “I think film in the installed base has gone virtually to nothing.”
CR offers a different story. While still considered digital, the technology lacks the workflow efficiency of DR, and sales have been declining over the years. While CR made up 55% of new digital x-ray sales in 2006, that number fell to just 6% in 2015, with the rest of digital x-ray sales made up by DR, according to IMV.
Still, years of strong CR installations mean that the technology still makes up a significant part of the installed base of digital x-ray systems, unlike analog x-ray, Young said. In IMV’s 2015 report on the x-ray market, the firm estimated that there are 16,775 fixed general x-ray systems installed at hospitals in the U.S. (a figure that does not include mobile units or systems installed at outpatient locations). Of that total installed base, some 8,545 systems are CR.
Click image to enlarge.
Imaging facilities will therefore have to decide whether to spend the money to upgrade their CR equipment to DR, or swallow a 7% to 10% reduction in payments for x-ray studies. Many of these facilities are located in rural areas, with less access to the capital needed to buy new equipment.
In its 2015 x-ray market report, IMV said that 62% of hospitals were already planning to buy either a new x-ray system or a DR retrofit kit in the coming years. Of these, 70% of sites with fixed CR systems are planning purchases, Young said, while only 34% of sites with fixed DR are making purchasing plans — perhaps indicating their satisfaction with the newer technology.
Converting to DR will produce workflow and efficiency gains — as well as lower radiation dose — for the U.S. hospitals that finally make the switch to fully digital operation, according to ACR’s Moran.
“Clearly analog is felt to be antiquated and not helpful. CR is clearly less antiquated, much more in use, and has many advocates for it, but even that market is moving fairly quickly to digital,” she said. “This policy just furthers that along.”
For Varian’s part, the company sees its support for the legislation as adding impetus to a positive trend in healthcare, according to Spencer Sias, vice president of communications and investor relations at the company.
“We believe that digital imaging makes it possible to lower the cost per procedure by allowing for higher throughput in imaging centers,” Sias told AuntMinnie.com. “We eliminate the need to buy, process, develop, and store film. That is a very good thing in an age when the cost of medicine needs to be held in check.”
The Major Differences Between Digital Flat Panel Detectors
Their are two main types of Digital Flat Panel Detectors (FPD’s) in use today and they are DIRECT and INDIRECT CONVERSION FPD’s.
Direct Conversion FPD’s have one less step in the conversion process of obtaining an electrical charge for a digital image directly from the FPD. Since these type panels have one less step in the conversion process they also have a higher MTF, DQE and lp/mm resolution than Indirect FPD’s. Here is how they work.
Direct Conversion FPD’s
Direct conversion detectors have an x-ray photoconductor such as Amorphous Selenium ( a-Se), that directly converts x-ray photons into an electrical charge. That charge is then processed by either a TFT (Thin Film Transistor) or CMOS (Complementary Metal Oxide Semiconductor) array and sent off to the imaging computer for processing and further conversions.
Indirect Conversion FPD’s
Indirect Conversion FPD’s have an extra process involved in the conversion of x-ray photons to an electrical charge. Indirect FPD’s first have a scintillator layer that converts x-ray photons to light. The light is then converted to an electrical charge by means of photodetectors with a thin layer of Amorphous Silicon (a-Si). The photodetector diodes are doped with a thin coating of either crystalline cesium iodide scintillator (CsI) or a rare-earth scintillator Terbium-doped Gadolinium dioxide sulfide (Gd2O2S) or (GdOS) hence the terms GdOS and CsI FPD’s.
Chances are you were sold and told you have Direct Radiography FPD Imaging Technology when in fact you have Indirect Conversion FPD Digital Radiography…..there IS a difference!
If you have a FPD made out of caesium iodide (CsI) or gadolinium oxysulfide (Gd2O2S – GOS) also known as GdOS you have an Indirect Conversion FPD Digital Radiography X-Ray system. But don’t worry until you read the rest of this article!
Ok, so now we know the differences of Direct Conversion FPD’s and Indirect Conversion FPD’s…..so how much of a difference is there REALLY between the two technologies and prices? Well, let’s find out!
Diagnostic Conclusion of Direct FPD’s and Indirect FPD’s
Although indirect panels lose the battle of the DQE, MTF and CNR wars of comparing image quality they do not lose by much. The cost benefits of indirect FPD technology usually outweigh the slight loss of resolution obtained by direct conversion FPD technologies.
There are also big differences in how the elements of direct and indirect panels react to KEV energy ranges which actually makes the indirect FPD more desirable for most general studies. Currently the direct conversion FPD’s are mainly used in mammography as they have a higher DQE, MTF, better CNR, Resolution and react better to lower KEV energies than do indirect FPD Digital Radiography systems!
So now you know it all………..
I’m sorry to tell you this but there is much-much more you need to know before biting the bullet and purchasing a Digital Radiography FPD System……
Our next article will compare the differences between CsI and (Gd2O2S – GOS) or GdOS Indirect panels……there is a difference and you will be surprised at just how this difference will affect your exam x-ray techniques and dose needed to acquire a readable radiograph!
Other future articles:
CMOS versus TFT electrical conversion in FPD’s…..which is better?
Computer software imaging algorithm’s….which OEM has the best images?
Digital FPD Fluoroscopy versus Image Intensified CCD Digital Fluoroscopy…..who wins?
11-19-15 DR vs. DR vs. DR………say what?
In this article we will be discussing the differences between DR Direct Radiography, DR Indirect Radiography and the other DR Digital Direct Radiography. Confused? This article may help.
Direct Radiography consists of two separate terminologies depending on who you ask. If you ask most x-ray technicians and DOR’s they will tell you Direct Radiography consists of a Flat Panel Digital Detector (from here out referred to as an FPD) and computer. This terminology suits them well as in a sense it is Direct Radiography. Position the patient, set your techniques, make an exposure and WALLA a digital image appears….how more direct can you get?
Direct Radiography to a knowledgeable service engineer means something different as there are major differences between what x-ray personnel call Direct Radiography and what actually DR Direct Radiography is. Don’t be fooled by salespersons that say they are selling you a Direct Radiography system because chances are they aren’t.
So let’s get this differing of terminology out of the way first. Direct radiography from a technical and product point of view is actually what the FPD is made of and NOT just any system that produces digital images by means of a Digital Detector with no more user actions necessary.
There are two main types of Digital Flat Panel Detectors (FPD’s) available:
Direct X-Ray conversion Flat Panel Detectors (hence our terminology of Direct Radiography)
Indirect X-Ray conversion Flat Panel Detectors
I am not going to bore you by chasing photon’s around and the processes involved on how they are converted into a digital image as that is a topic on it’s own and something else you need to know if you want to purchase the correct FPD for your specific exam studies. I am going to tell you in layman’s terms that Indirect FPD’s have an additional step involved in turning x-ray photons into an electrical charge to digitize and that extra step does affect image resolving quality substantially.
So, with that being said…..Direct Radiography is simply a FPD that converts x-ray photons more efficiently to an electrical charge and thus has a higher resolving quality over indirect FPD’s. All other forms are simply digital radiography.
OK, now that I got that off my chest let’s get to an easier distinction of DR – Digital Radiography.
Digital Radiography can be achieved by either of these 3 means:
A direct or indirect FPD
CCD camera systems
FPD’s have 3 basic configurations:
(not including various compositions like a-SI, GOS or a-SE materials which does effect image quality. These will be reviewed in our next article.)
The Ace of Spades:
Wireless FPD’s – Wireless FPD’s are considered Direct Radiography in the sense that you expose the plate and receive an image without any additional user steps. These FPD’s can be used in many ways that a fixed or tethered FPD can not. Wireless FPD’s work well with portable x-ray equipment as well as in a radiographic room. Simply place the detector in the type of receiver you wish (wall bucky, table bucky or table top) and your ready to start the exam.
Pro’s of Wireless (WIFI) FPD’s include:
It’s ability to give you high quality digital images remotely with no attached wires.
Very universal as you can also use them in general radiographic room exams.
Better images than CR
Improved work flow over CR
Your trauma doctors will love you as they can now review instant high quality digital images in seconds!
Con’s of Wireless (WIFI) FPD’s include:
Damaged FPD’s from dropping them or accidentally striking them anywhere with enough force that they are damaged. This happens A LOT and will cost you around 2/3rds of the initial cost of a new one panel wifi system.
Cost, more expensive than fixed or tethered FPD’s however due to competition the costs have come down drastically.
The King of Hearts:
Fixed FPD’s – Fixed FPD’s have all the same qualities as WIFI FPD’s except the abilities to use them remotely and the ability to use one detector in multiple room receivers such as wall bucky and table bucky. For this you would need two fixed FPD panels.
Pro’s of fixed FPD’s include:
Lower price than wireless detector’s. (around $4K to $10K lower)
Much better image than CR
Improved work flow over CR
Detectors can’t be dropped like wireless and tethered detectors can.
Con’s of fixed FPD’s include:
Not multi-purpose like wireless and tethered FPD’s….takes two detector’s to do wall and table bucky studies.
No remote capabilities
No table top exposure studies
The Queen of Diamonds:
Tethered FPD’s – Tethered FPD’s have all the benefits of wireless (WIFI) FPD’s except the panel is connected to the equipment by a tethered cord. Tethered FPD’s are also limited by the length of the tethered cable. The Pro’s and Con’s are similar to wireless except that once the tethered cable gets damaged (and it will) you may be in for a spendy repair bill.
The Jack of Clubs:
CR – CR is on it’s way out….period. The images aren’t as good as FPD’s, the work flow isn’t as good as FPD’s and they can also require more maintenance and repair calls than FPD systems. Unless CR drops it’s price to a ridiculously low amount not even Chiropractors will choose these systems as FPD’s are right there in the same price range of a decent CR system.
And the Loser of the hand is?:
CCD – There are still a lot of people peddling CCD radiographic systems. Unless you want your x-ray room to be as hot as a sauna (the CCD cameras put off a lot of heat and there are multiple camera’s per system, sometimes hundreds), want lower quality images than FPD’s, want a bulky detector head and a higher maintenance cost I would steer clear of these systems. CCD technology is still viable for fluoro and c-arm systems but not so much with general radiographic use. FPD’s are also a viable technology for fluoro and c-arm applications but come at a higher price. The G.E. Innova cath lab fluoro systems I have worked on utilized a type of FPD that has excellent imaging resolution with little to zero lag you can
get with CCD systems.
I hope this article helped…..our next article will cover the differences between various Direct FPD’s and Indirect FPD’s. The materials these FPD’s use and the Pro’s and Cons of each panel system. If you plan on purchasing a new FPD system this is a must read or you can contact me at :
Here are some general details about DR versus CR imaging systems. We are not even going into the Digital Radiography versus film based radiography argument as the point is mute. Digital radiography is here to stay and film based systems are on their way out! Two days before writing this I received an e-mail from my Fuji film distributor listing certain types and sizes of x-ray film that will no longer be in production, so if you haven’t gone digital yet, it will only be a matter of time before your forced to bite the bullet or stop taking x-rays altogether. So, with that in mind, here we go!
First off, both CR and DR are forms of digital radiography. CR stands for computerized radiography while DR stands for direct radiography. In other worlds DR also stands for digital radiography but for this article we are referring to DR as “Direct Radiography” and CR as “Computerized Radiography”.
So let’s start with the ugly cousin…..CR.
CR gets a bad rap for a couple of reasons:
The amount of time it takes from exposure of the patient to actually seeing an image takes minutes versus a few seconds with DR systems.
The additional steps in the process of obtaining an image.
Image quality is not as good as most DR systems.
Labor intensive maintenance if the system goes down. (Note: Fuji CR systems are basically built like tanks and I have had few problems with well maintained Fuji CR systems)
The most common complaint I have received about CR out in the field is the process involved from start to finish in acquiring an image to enhance. This seems to be more of a concern with busy imaging centers and radiology departments especially those with more than one x-ray room that utilizes only one CR reader.
The steps required to obtain a CR image go like this:
You place the needed cassette size/required image size, just like film imaging, into the cassette holder.
Line up and position the patient.
Dial in your techniques and make an exposure.
Remove the imaging cassette from cassette holder (wall bucky or table bucky).
Enter in patient info into the system, if you haven’t previously done this, and insert the imaging cassette into the CR reader.
Either wait for the image to be scanned and pop up on the screen for review and digital enhancements or repeat steps 1-5 with another image you must take.
Digitally enhance, place markers or perform other software image protocols and send the image through to pacs or view the image at the reader workstation.
This is very similar to the steps required for film processing.
The biggest differences between film and digital CR images are you now have a high quality digital image that can be enhanced and marked up by a large number of software utilities, can be stored on a pacs system, local hard drive or cd rom and can be sent anywhere in the world with a few clicks of a mouse. You no longer have to purchase film, x-ray chemistry, monthly cleanings and you have no need for a dedicated darkroom or film storage area. Digital imaging also reduces the need for many retakes due to poorly selected x-ray techniques as the images have a wide latitude of adjustment by the computer aided software.
Now let’s review Prince Charming……DR
DR gets a bad rap for two main reasons:
It’s much more expensive than CR.
The imaging plates are very fragile and for non fixed systems, if they are ever dropped and damaged, your in for a bill that will be about 2/3rd’s of the entire systems original new price. And it does happen, quite often!
DR utilizes a direct imaging plate that is either fixed, tethered with a wire harness or wireless imaging plate. With a DR system there are basically only a couple of steps:
Position the patient.
Select your exam technique and make an exposure.
The image will pull up on your computer screen in 3 to 10 seconds depending on the system you purchased. Now all you have to do is enhance the image if necessary and add any markers or perform any other software protocols you choose that are available and then save it or send the image to pacs. DR systems also have the other benefits of CR systems such as no more dark room, no need to purchase film or chemistry and you store images in the same manner as CR so no need for expensive storage space.
This is just a basic over view of C vs. DR and there are plenty of other online resources to choose from….some good and some bad…..if you have any further questions feel free to contact us!