The word came like the last newspaper delivery at the end of the world, unsettling and resounding like a death knell throughout the radiology field: Fujifilm Medical Systems USA would be phasing out the production of medical film products at its Greenwood, S.C.-based facility.

Spurred on by the market shift toward PACS solutions and a decade-long decline in medical film sales, Fujifilm opted to consolidate the production of all medical film to a single facility in Japan. While Fujifilm has promised that delivery of film to its current customers will continue without disturbance, the news has become a harbinger of a digital future for many analog film users.

Digitally Resistant Radiologists

With the advent of PACS and radiology information systems (RIS), as well as the growing trend of electronic medical records in the United States, the allure of all-digital radiography departments has spread swiftly among major urban imaging centers.

However, while these imaging centers are the most eager to move into the digital frontier and raise the bar on patient imaging procedures, they are among the few facilities that are able to do so without being overly concerned about the devastating cost of such a changeover.

Guaranteed a higher patient volume, larger imaging centers are also able to ensure a timely return on their investment with a digital imaging system, which can be as much as three to four times more expensive than an analog system.

“It basically boils down to cost and volume,” says Richard Budde, Jr, MD, medical director of radiology at The Christ Hospital in Cincinnati.

“A digital system is a significant cost upfront, but with improved personnel efficiency and the operational expense savings by eliminating film, chemicals, and processing equipment, a department with sufficient volume can save money in the long term. Ultimately, its a cost-differential issue – if the institution does not have the capital and the caseload to support it, the numbers will not justify the complete switch over to a dedicated digital radiography system.”

Inadequate patient volume is precisely the reason smaller, urban hospitals and, especially, rural hospitals are slow to integrate digital systems into their facility. Imaging center administrators are accustomed to looking at department finances on a quarterly basis, and expect a more immediate return on investment for any major acquisitions.

Merely eliminating film costs and reducing the staff necessary to maintain the film library are not enough to validate the purchase of costly digital systems and the accompanying PACS, especially when the analog system already in place is sufficient to handle the relatively low imaging needs of the hospital.

Moreover, these smaller facilities must often consider the comfort and capabilities of their present staff when opting for a digital system. A technologist accustomed to using a view box for films will sometimes have a difficult transition when moving to viewing images on a monitor.

The digital system allows for electronic artifacts and additional viewing options that techs might not have encountered on the analog system due to technological constraints.

Therefore, they will need tutorial sessions before they can fully utilize the digital system’s resources. Facilities unable to make the drastic digital installations are instead making gradual shifts from film to digital, beginning with modalities such as MRI, CT, and ultrasound – areas in which hanging and maintaining films is becoming a tedious process.

“There is going to be a ‘cross-over’ stage where you still have the old film studies, with the new digital studies coming in, and the facility must match them up,” says Greg Rose, MD, PhD, president and CEO of Bellaire, Texas-based NightRays teleradiology services.

“The challenge comes in trying to orchestrate the co-existing technologies until the older technology finally ‘sundowns’, which could still be as many as seven years, according to the [American College of Radiology]. These professionals are not only taking on a new technology, but [they’re] also having to maintain the old technology. So, it isn’t really, ‘out with the old, in with the new’ – professionals have to negotiate both of these technologies.”

Last Refuge for Film

The phase-out of American film production from Fujifilm is not the only tell-tale sign of how the industry is changing pace to embrace digital systems.

Of all the modalities, mammography has been the slowest to enter the digital arena, with film-based analog systems still comprising 80 percent of the mammography units used in the United States.

For a time, even while ultrasound and MRI units transferred over to digital imaging, mammograms provided the hallmark “call to arms” for those radiologists who were concerned that digital systems did not provide the same pixel resolution as analog – in fact, producing poorer images.

However, recent studies are demonstrating that even this rallying point for film-enthusiasts may be fading fast.

According to new results from the Digital Mammographic Imaging Screening Trial (DMIST) published in a recent issue of Radiology, women under the age of 50 with dense breasts, and who are premenopausal or perimenopausal, get more accurate results with digital mammograms.

Thirty-three U.S. imaging centers registered more than 49,000 women in the study – first published in 2005 – to evaluate the varying breast cancer status of more than 42,000 patients. Researchers have recently returned to the results of this study in order to verify which of three factors was most important to the discrepancy in diagnostic accuracy – menopausal status, age or breast density.

While both film and digital-based mammograms involve breast compression between two plastic plates, the digital unit has the advantage of recording images faster, while using less radiation.

Furthermore, radiologists can manipulate these digital images, changing the brightness and contrast to achieve maximum viewing, which is especially important when imaging women with dense breast tissue.

Both dense tissue and cancerous lesions appear white on a mammogram, so it is necessary for the radiologist to use a range of viewing contrast options until the cancer becomes distinct from the breast tissue.

“The results of our study confirm that women under 50, who are pre- or perimenopausal, and have dense breasts, should be screened with digital, rather than film, imaging,” says Etta Pisano, MD, senior author of the study, and the Kenan professor of radiology and biomedical engineering at the University of North Carolina in Chapel Hill.

“However, we also found a non-significant trend toward better diagnostic accuracy in film for women with fatty, rather than dense, breasts over age 65. We’re still trying to figure out why that was the case for this particular subgroup – at this time, we don’t have an explanation.”

Although the study demonstrates that the digital mammograms identified 28 percent more cancerous lesions than film-based mammograms for the women targeted in the study, digital dominance is far from complete.

Priced as much as five times the cost of film-based units, some experts argue that digital mammography simply doesn’t yet offer enough of an edge over film to validate its purchase. Film may be down, but definitely not out, they say.

Film Survivalists

Despite the lack of funds or unfamiliarity with the technology, many radiology departments outside of the major medical centers are gradually being pushed into the digital age. However, rural facilities equipped with analog systems and small staffs are faced with enormous financial pressure from the healthcare system.

Expenditures for computed radiography (CR) systems, much less a digital system, are not often supported in budgets maintaining such low imaging volume, and courier services for sending films to specialist readers can also provide additional burdens on already strained finances.

To survive these early years of the digital age, many remote facilities have turned to analog digitizers as the “Swiss army knife” for rural radiology – flexible, easily integrated, and cost-effective.

“Outlying centers must provide a high standard of care to their patients,” says Mary Harp, director of the film digitizer business line at Herndon, Va.-based VIDAR Systems Corp.

“Part of this may be achieved by contracting services from a remote radiologist for reading by having the patient X-rayed locally, as opposed to forcing them to travel to the radiologist; a great example might be retirement communities and assisted-living centers, or truly rural locations. In order to raise the standard of care and lower costs, existing analog equipment continues to be used at the rural clinic to X-ray the patient, and using a film digitizer is the least costly path – from an acquisition standpoint – to create a digital image which can then be transferred to the radiologist for reading. Small facilities find it more difficult to justify larger capital expenditures, such as DR and CR, which will take much longer to regain [return on investment].”

In rural facilities, digitizers are providing the necessary boost for staff and patients struggling with the pressures of going “all-digital”. At minor imaging centers, digitizers can be used to send film copies to referring doctors, or to digitize films coming into the hospital from outside sources and add them to the patient’s electronic medical record.

Digitizers also allow rural hospitals to transmit nighttime radiographs to specialists at larger hospitals for a preliminary interpretation, while the staff radiologist uses the actual film for the primary read. In extreme cases, some facilities have used digitizers to convert portions of their film archives into soft-copy records, although this process is often too time-consuming for practical applications.

“It would be great for [rural facilities] to go to CR so you could still window and level the images, but studies are finding that analog film can frequently give you a better full-grayscale depth than CR,” says Rose.

“Once you scan it, though, you do lose some aspects of the contrast resolution. There are camps on both sides of this debate. If professionals go with CR, they really have to count on their technologist to get it right – it’s very tech-dependent, and they really have to refine their technique.”

To meet the need for digitizers in the rural market, VIDAR Systems has designed a system specifically for low-volume radiology applications – the Sierra Plus film digitizer.

Engineered for the smaller facility, the American Çollege of Radiology-compliant Sierra Plus is small enough to be easily wall-mounted, which prevents it from hindering the movement of professionals around the office.

While this kind of film digitizer may provide smaller imaging centers with the ability to forestall the end of film for years to come, many professionals are still concerned about the standard of care given to patients whose preliminary or primary reads are maintained by these film-based images.

“Film digitizers were utilized early on during the change over from analog, and there are facilities that are still trying to bridge the gap with them,” says Budde.

“However, the diagnostic quality is inferior, and the radiologist’s ability to manipulate the image is limited. The dilemma occurs when you produce a poor image on hard copy and then scan it into the digitizer for display. The additional information loss in the analog-digital transfer compounds the problem of the suboptimal resolution in the originally acquired image.”

Weathering the Digital Storm

Market experts are still hard-pressed to say how fast digital radiology will spread in the United States. Several major vendors have invested their company heavily into digital radiology systems, and some have even risked stranding themselves waiting for the buyers’ market to catch up.

Many industry experts have predicted a transition to a completely filmless industry in only 10 years, while others, seeing the resistance of many rural facilities, have placed it as far away as 30 years.

Medical film has served as the reliable viewing foundation for almost all of the imaging techniques and specialties used today, and many radiologists and technologists remain faithful to the traditional analog systems.

Aware of film’s strengths, boundaries, and limitations, many older professionals are hesitant to plunge into another system that does not correspond to the standard set of restrictions; some radiologists feel they may be simply too set in their analog ways to serve as an effective reader of digital radiography.

Even years from now in the swell of the digital age, there will likely be those professionals who, despite all the electronic marvels at their fingertips, still need to connect – to touch – a film image to read it properly.   

— Bob Stott is a staff writer at rt image. Questions and comments can be directed to bstott@rt-image.com.