Even as DR gains in popularity among acute care and outpatient care facilities alike, traditional CR retains and maintains a solid fan base.

With technological advancements stepping up multiple notches, the past few years witnessed a progressive shift in the radiology market from analog to digital systems, with cost savings, efficiency, productivity, and patient-centrism being pillars of the value-based imaging. Reduced scan times and improved image quality have been the driving factors for the rising popularity of digital radiography (DR) systems.

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. In India, while many facilities are transitioning to the benefits of DR, it appears that CR will remain a viable X-ray solution for years to come. However, on the global front, there is still a dilemma. Imaging facilities are yet to decide whether to spend the money to upgrade their CR equipment to DR, or swallow a 7 percent to 10 percent reduction in medicare reimbursements for CRs. Many of these facilities are located in rural areas, with less access to the capital needed to buy new equipment.

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The benefits of DR are widely recognized by the medical imaging community. And while film is a time-proven capture medium that can produce quality diagnostic images, it has its drawbacks as well. It is a slow process, requiring the processing of the film after it is exposed. This in turn necessitates the use and handling of harsh, toxic chemicals. These consumables and the film itself are a constant and ongoing expense; also, the film requires significant floor space for storage.

Filmless radiology departments are the way to go and most large hospitals in the corporate sector have adopted the DR systems leading to revenue saving. Better detectors, faster processing, more powerful computers, bigger and sharper displays, and efficient archiving are transforming the way one looks at medical imaging. Higher-grade medical viewing monitors provide excellent image quality. One thing is certain – the future of DR is wide open. Beyond dose issues, most buyers' checklists of needs focus on three points: extremely reliable direct DR solutions, flat-panel detectors providing excellent image quality, and systems with flexible usability. Over the next few years, what they are really looking for is more utilization in leveraging the equipment that they have in place to do more things. So the radiology department has to become more competitive and be able to do more things for doctors.

Indian Market Dynamics

The X-ray equipment market is growing exponentially with an increase in the number of imaging centers. The growth in the analog segment is stagnant, while the digital radiography systems acquire market share due to wider adaptability.

The market players are expanding their product portfolio keeping in mind the price constraints in the adoption of DR systems. The latest generation of X-ray detectors and radiography-cum-fluoroscopy systems are gaining traction. The demand for indigenous systems and refurbished systems is steadily growing. With the Make in India initiative providing the requisite impetus, the indigenous players are keen to match safety features and offer competitive price points.

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2016 saw a unique teleradiology public-private partnership. Fujifilm India Private Limited signed a contract with KRSNAA Diagnostics Pvt. Ltd., to install 1000 CRs across India. This enables converting X-ray setups from analog to digital and patients getting immediate reporting through teleradiology, especially in remote areas, where senior doctors are not always present. This installation reduces reporting time and delivers enhanced image quality, aiding in better diagnosis. This is a two-year project and FujiFilm will supply and install 1000 units of FCR Prima and 1200 units of DRYPIX imager. The first phase covers all the districts of Assam, followed by Telengana.

This year was also when demonetization saw a flurry of purchases of machines, followed by a slump, especially in case of smaller setups.

Global Market Dynamics

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The global X-ray equipment market is projected to reach USD 11.92 billion by the end of 2021, growing with a CAGR of 5.0 percent from 2016 to 2021, estimates Infinium Global Research. The global X-ray equipment is dominated by CR systems as they are relatively less expensive than DR systems and entail less retraining of medical practitioners. The market for digital X-ray equipment will grow impressively at a CAGR of over
13 percent by 2020.

The demand for digital X-ray equipment is growing at a significant rate since the procedure forms the basis of diagnosis and also the treatment of various medical conditions. Tele-imaging enables healthcare professionals to perform and interpret medical images from remote locations, where technology is hard to reach. The teleimaging technology has undergone significant technological advancements which let the doctor or hospital to share videos and images of ultrasound via the Internet, using an IP camera and remote access software. This technology allows real-time teleradiology expertise in the presence of a junior sonographer or radiologist at the patient center. It helps in reducing inpatient care and will be efficient in handling the shortage of the physician's workforce. Moreover, the introduction of fully automated, versatile, and easy-to-use digital X-ray systems has led to significant expansion of teleradiology and teleimaging in remote areas, which will drive this market's growth over the next 4 years.

The top three emerging trends that Technavio healthcare and life sciences research analysts cite as driving the global digital X-ray equipment market include:

Reduction in reimbursements for film-based X-rays and CR. The market has witnessed a reduction in reimbursements for film-based X-rays and CR, which will fuel the market for digital X-ray systems. This is a clear indication to incentivize the transition from traditional X-ray imaging to digital X-ray systems. With such acts in the market, the vendors are seeking to adopt digital X-ray systems to gain cost advantages. For instance, in May 2016, Agfa HealthCare launched a DR upgrade program, which provides a quick transition from traditional film-based X-ray systems to digital X-ray systems. The company provides hospitals a step-by-step guidance to transition to the DR even in the absence of immediate capital.

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New product launches coupled with technological advances. New products featuring advanced technologies will substantially drive the market. The advances in technology of radiographic systems used in routine examinations (chest, neck/spine, and limbs), specialty services (dental and mammography), and emergency services (ICU, neonatal ICU, and hospital wards) have resulted in the development of new radiation sources and technologies by using neutrons and X-rays. The advance from analog to digital X-rays has led to the development of many applications and radiation-based imaging techniques. The introduction of flat panel CR in X-ray equipment has increased their efficiency and imaging quality. Digital imaging has revolutionized the imaging industry by replacing conventional film-based radiography that uses X-rays/neutrons. Images can be stored in electronic format, which can then be enhanced to achieve optimum results. In addition, reducing the radiation dose and using high-sensitivity plates enhances the sharpness and resolution of the images.

The vendors in the market are launching new software that is compatible with the existing digital X-ray equipment. In May 2016, Varian Medical Systems launched a new computer-aided engineering (CAE) software to simplify the process of shielding and radiological protection systems design. Such new product launches enable vendors to generate substantial revenue and thereby boost market growth.

Emergence of portable digital X-ray equipment. One of the upcoming trends gaining traction in the global market is the emergence of portable digital X-ray equipment, which is expected to witness a faster growth during the forthcoming years, at a CAGR of 7.2 percent. The portable X-ray systems circumvent the need for a technician to develop the X-ray, or physically transport it from one location to another. In addition, handheld systems are increasingly used in emerging applications such as veterinary, medical, military, customs screening, and security checks. Further, the portable digital X-ray equipment has huge potential, as the current adoption rate is around 15 percent. This means that there is a potential pool of 85 percent of customers who may switch from portable analog X-ray equipment to portable digital X-ray equipment in the near future.

In terms of geography, North America region remains the major market followed by Europe in the actual period. APAC region will witness strong growth driven by the countries such as India and China.

While developed regions will continue to dominate the market in terms of revenue, emerging nations are expected to respond to the market optimistically due to the developing healthcare infrastructure, leading to increase in hospitals and rising focus on healthcare among the growing middle-class population.

Rising awareness for diagnosis of lifestyle diseases coupled with improved technology in imaging has shifted demand for X-ray equipment market. Market for X-ray equipment is growing steadily due to rise in the lifestyle diseases, which has led to early diagnosis among the population. Also, due to the definite lifecycle of the equipment, growing replacement demand has also been fuelling demand for X-ray equipment.

Adding Edge to Technology

The X-ray equipment market is flooded with the key players bringing in the best-possible digital radiography systems offering cutting-edge digital enhancements. The healthcare providers want to leverage their existing imaging investments yet generate higher-quality images with the potential for lower radiation dose. Some of the newest systems have focused on improving productivity and workflow for more efficient operation and cost control.

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Recent studies have revealed that a sheet of graphene can be used to generate surface waves known as plasmons when struck with photons from a laser beam. Plasmons can further release a sharp pulse of radiation that can be tuned to uniform X-ray wavelengths. This radiation is said to be relatively safer, as it can result in lower-dose X-ray systems being built in the future.

A research group at the University of Waterloo patented an innovative technology to create a digital X-ray imager that can be built by a typical flat-panel display manufacture, 25 to 50 percent more sensitive than current digital imagers. The technology can also provide improved visualization of soft tissue and bone comparable to CAT scans by using a single exposure dual-energy X-ray approach, which offers 50 times less radiation to the patient than a traditional CAT scan.

A team led by UCL scientists has successfully developed a new X-ray imaging technology that excels at determining different shapes and types of matter – a capability that conventional X-rays could only match by using prohibitively high doses of radiation. This phase-contrast X-ray imaging technology can be utilized to identify tumors in living tissues.

Industry vendors have been working to provide solutions, and 2016 witnessed the introduction of several new products designed to aid the transition from analog to digital in different ways.

New wireless detectors. The latest generation of wireless DR detectors with automatic beam detection achieves the traditional use case of both CR and film, but with the benefits of much higher throughput and improved dose efficiency. Automatic beam detection capability enables a simple path to digital retrofits, since no integration with the X-ray generator is required. State-of-the-art DR panels are now equipped with a data-processing engine and carry their own calibration files, which allows the images to be corrected on the panel. With the calibration data stored on the panel, the DR cassettes are more portable between the equipment and the rooms. On-panel image corrections decrease the image transmission time and improve the wireless link robustness by reducing the number of images transmitted with each image acquisition.

Dose efficiency. Both GOS (gadolinium oxysulfide) and CsI (cesium iodide)-based DR detectors have higher dose efficiency than CR. With increased dose utilization, DR can produce the same image quality as CR at a lower dose and can produce higher-contrast resolution images than CR using the same dose. The cesium-based detectors feature automatic exposure detection for easy install without connecting to a generator interface cable.

Sharing equipment. Using Bluetooth, the most advanced detectors are designed to connect automatically to equipment that controls the X-ray tube and generator. Installation is accomplished with a wireless access point through which images can be sent for display or storage, image processing software, and a display screen. Auto detect features are staples in new products and can be used to control detectors and other X-ray components at multiple locations in a facility.

Road Ahead

X-ray imaging has come a long way with the forefront technologies in the DR systems. Equipped with the finest imaging machinery, these systems offer enhanced sharpness and clarity along with the dose-reduction techniques. Future DR panels will enable advanced applications like tomosynthesis and dual-energy imaging. In the near future, DR upgrades will soon be available for multiple imaging labs utilizing a common server, instead of multiple individual consoles for each room. Ultimately, these advances will greatly improve patient care by maximizing imaging efficiency while minimizing radiation exposure.

Chander Shekhar Sibal,Executive Vice President,Fujifilm India
Industry Speak
Digitization Is the Future

Healthcare market in India is growing at a rapid speed and government hospitals and state governments are taking PPP route to improve the infrastructure and digitization of X-ray. Teleradiology and PACS are becoming necessities due to huge patient load and less number of doctors. GST is going to be a key enabler of making One India One Tax and this would lead to increase in efficiency and reduce wastage in supply chain management. Healthcare delivery in India is now uniquely composed to undergo a change at all its stages – prevention, diagnosis, and treatment. Government is taking many steps for improvement of healthcare sector by promoting routine and proper screening health education programs in Tier-II and Tier-III cities.

Our focus is on Tier-II and Tier-III cities and on the process of digitization in medical industry. Most of the time, government projects are delayed which is a hurdle for us as we are going through public/private partnership. But I believe with the help of GST, we can be in a better position as transporting products within the country is feasible now. This would also help in reducing the warehouse and transportation cost.

The buyer wants faster services and new technologies, which give exceptional image quality at lower dose and enhanced efficiency of point of care X-rays.

In this era of digitization, the quality of workflow is getting better; the efficiency of people is increasing in the hospitals. With the help of technological advancements, doctors are able to manage workflow systems and are able to treat more patients. Healthcare is reaching Tier-III cities and capturing villages where various screening programs are initiated by the government for healthy India

And recently, the government has come up with a new policy where preventive healthcare is very important. It is better to be healthier than falling sick as that expenditure is huge. We need to focus on hospital's expenditure to be more equipped with better technology. Digitization is the trend and it will go further, better-quality equipment would bring more work flow, which will bring better-quality workflow.

Chander Shekhar Sibal
Executive Vice President,
Fujifilm India

Amaresh Kumar,Application Specialist,Skanray Technologies
Industry Speak
Changing Trends in the Imaging Industry

The medical device industry is transitioning fast to keep pace with the changes in the healthcare delivery industry. As pressure mounts on hospitals to improve efficiency with meager increase in resources, a large part of this exercise tends to focus on increasing productivity of existing resources and deriving larger return on investments on devices and equipment.

Imaging companies across the globe have more or less adapted to the fact that the demand for products with good enough features and that are competitively priced are going to drive the market globally in the next few years. The situation is not restricted to emerging markets alone. Even the developed countries are facing tighter cost controls and lower reimbursements, which are pushing them to adopt these products.

The imaging equipment market comprises a mix of large multinational companies and local companies and there is a significant overlap of the target segments of both. With the MNCs also bringing in the de-featured products to be cost-competitive, the differentiation tends to largely focus on highlighting the lower cost of ownership, service promptness of the field force, and robustness of the equipment, which is typically seen in small-value products. In the large-value deals, the proposition changes a bit to include other add-ons such as education and training of the staff on the usage of the equipment, workshops, loan and EMI facilities, pay-per-use model, lease model, and turnkey projects.

With all this focus on value-products, the larger companies still package the innovations, which are out-of-reach for the local companies, in the premium products and offer them at premium prices. The hospitals which strive to position themselves as state-of-the-art hospitals, sporting the latest high-end equipment, are the target customers for these offerings. The decision-making process, which was earlier based on the doctor's feedback, now also includes other stakeholders such as the finance, administration, and the biomedical team. The procurement decision making is changing in tandem with external forces shaping the healthcare delivery industry. Companies offering performance products at competitive prices are poised to gain significantly from this change.

Amaresh Kumar
Application Specialist,
Skanray Technologies

Dilip Bhosale ,General Manager-Marketing,Agfa Healthcare India Limited
Industry Speak
Digital Radiography – Join the Digital Evolution

In an era of Going Digital, small diagnostic setups to largest corporate hospitals are upgrading their standards of digitizing X-ray. Decisions are being taken primarily depending on patient workload, examination type, and patient location. Other key factors include solution's capability to achieve fast and accurate X-ray images, array of post processing and measurement features, and cost effectiveness of the solution.

Enormity of data and options on the web makes selection complex. ROI (Return on Investment) for digitizing/upgrading X-ray remain a key driver. Key decision-making pointers summarized below will help make the right choice:

Existing and future patient workload. Selection for computed radiography (CR)/direct radiography (DR) critically hinges on this important factor. Speed of the digitizer or the DR modality to complete one examination needs to be evaluated. CR systems can easily complete 30 examinations per hour and DR systems are designed to handle at least 60. Patient preparation and discharge time after completion of X-ray needs to be considered.

Type of examination and patient status. CR systems can handle stationary, mobile X-ray systems, OPG units, mammography, and fluro studies. Using cassettes with cesium bromide base offers an advantage of acquiring DR-like quality with lower X-ray dose. ICU X-ray quality can also be enhanced using such special material cassettes. Suitable size and number of cassettes with longer warranties can meet the application needs and will keep total cost of ownership low. Selection of more expensive, mammo-compatible CR system needs careful review of expected workload.

Latest advance multi-scale image contrast amplification software along with higher grey-scale resolution can enhance X-ray images with excellent contrast and resolution. Important factor in this case is clinical validation of such software, which ensures fault-free detection of anomalies. Intuitive user interface for the workstation helps technicians to quickly learn the system and effectively handle the workflow.

Ultimately, the ideal way to digitally evolve radiography is to select a product/s, which can meet the criteria of speed, accuracy, quality, and cost.

Dilip Bhosale
General Manager-Marketing,
Agfa Healthcare India Limited

Suresh Sharma,Chairman cum Managing Director,Allengers Group of Companies
Industry Speak
R&F Tables at the Forefront of Advanced RF Applications

Even after the advent of several advancements in the patient imaging technologies, fluoroscopy is still a preferred choice of radiologists in most of the procedures. It uses X-rays for doing real-time patient studies including diagnostic and therapeutic. Fluoroscopy is done with the help of specially designed equipment, which incorporates a patient couch, X-ray source, and X-ray to light convertor. This equipment is commonly named as Radiography-Fluoroscopy Table (R&F Table). Since this equipment involves ionization radiation, which is harmful for the patient as well as the operator, so in many countries different regulations were set to use such equipment. Recently developed concept of remote controlled RF tables is widely accepted by the market as it protects the operator from radiation. Such RF tables can be operated remotely from well-shielded rooms, thus we can say it happens to work on zero radiation to the radiologist concept.

Throughout the journey of technological developments, the R&F tables have evolved a lot. Now the IITV system is being replaced with state-of-the-art dynamic FPDs (flat panel detectors). FPDs, being very sensitive to X-ray dose, need very small dose in comparison to the IITV. At the same time FPDs are very sleek in size and provide large patient coverage
(43 cm43 cm). With FPDs, now the most advanced applications like DSA (digital subtraction angiography), roadmap, vascular, and peripheral angiography procedures are easy to perform and with better results in terms of image quality and radiation dose. The image quality has improved many folds and this has opened new horizons for advanced examinations carried out on this equipment.

The RF table also offers features like tomography and tomosynthesis. These features have curtailed the requirement of CT scan in various diagnostic studies. TOMO images provide 3-dimensional images of human anatomy and show very vital and useful details that cannot be seen in 2-dimentional images. The other beauty of TOMO is the minimum X-ray dose, if compared with a CT scanner for a similar procedure.

Such equipment manufactured abroad is quite expensive for the Indian market. In the current scenario of high capital expense, buying such equipment is quite taxing for the hospitals. We at Allengers offer products with a lower life cycle cost, which ultimately benefits the patient treatment planning. Allengers has and does offer all types of such tables with IITV and dynamic flat panels, which offer a great value proposition to customers. The Allengers' systems bring on table great value to its customers in comparison to MNC products of similar specifications. Now we are confident that Indian patients will get world-class treatment using these indigenous and economical equipment made in India.

Suresh Sharma
Chairman cum Managing Director,
Allengers Group of Companies

Dr Madhur Saxena,Consultant Radiologist,Rukmani Birla Hospital and Research Institute, Jaipur
Second Opinion
Technology Trends – A Radiologist's Perspective

With continued growth and development in the field of imaging technology, we have travelled from conventional wet radiography to computed radiography to digital radiography in the last one century. These developments enable us to view X-ray images on computer screens, substituting the conventional films, and making it possible to use digital image modification. We can get high-resolution images as soon as the technician hits the exposure button, without wasting any moment in processing. These images can also be modified digitally as per requirement of diagnosis. Modification in obtained images not only helps to diagnose or rule out particular pathologies but also helps to avoid repeat exposure to the patient, in case exposure given by technician is suboptimal. Though this journey has lots of advantages but most significant are better imaging quality, reduced radiation dose, and scan time.

The demand for portable and mobile X-ray equipment has increased tremendously in the last few years and will continue to show an upward trend due to its convenience in use.

Being a radiologist, my views are more centered on growth of X-ray technology, providing better image quality and imaging capabilities, as well as on awareness and radiation dosage reduction rather than marketing perspective.

Current trends are toward reducing time in acquisition of scan and in reducing radiation doses. By application of ALARA (As Low As Reasonably Achievable) principle, we can not only reduce radiation exposure to the patient but also by modifications in equipment and technical expertise of radiation technologist, we can significantly reduce radiation exposure and time. However, in one way, reducing time of scan is itself a measure to reduce radiation dose because time is a dominant factor in total radiation dose given to the patient during the scan. CAD (computer-aided detection) is advancement in improving diagnostic accuracies. Artificial intelligence in radiology, 3-D imaging, and IoT (Internet of Things) are fields of continuous research.

In conclusion, I think the greatest challenge in using modern radiation devices is to use them wisely. With right guidance and training to effectively use medical radiology devices, we can optimize use of imagining modalities for the mankind.

Dr Madhur Saxena
Consultant Radiologist,
Rukmani Birla Hospital and Research Institute, Jaipur


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