DR solutions are providing beneficial reductions in the three most important areas - money, time, and dose.

Indian healthcare industry is growing at a tremendous rate with a large number of hospitals and diagnostic centers being set up. Imaging equipment being an indispensable part of most medical centers, the market is experiencing steady demand. The shift from analog to digital models owing to the better imaging results of the latter as well as willingness of medical centers to improve their services continues.

Now, more than ever, hospitals and imaging clinics are trying to maximize the value of their imaging equipment, and digital radiography (DR) solutions in particular are proving to be a source of profit for many organizations. Doing more with less is the goal, and DR systems are providing beneficial reductions in the three most important areas - money, time, and dose.

Indian Market

In 2015, the Indian X-ray equipment market saw an overall decline of 20 percent in value terms. The analog equipment market is continuing to see a decline, whereas the DR systems are in demand. The fluoroscopy segment, which comprises analog, digital, and IITV contributed about Rs.25 crore to this segment. Showing a continuous X-ray image on a monitor, much like an X-ray movie, this segment is preferred by the discerning customer.

The CR (computed radiography) equipment market in 2015 maintained its sales of 4100 numbers valued at Rs.246 crore, similar to the 2014 level.

The procurement by government facilities continued to be for high-end equipment. The private sector was more prudent and opted for a mixed bag as per their requirement and budgets.

When comparing CR and DR, each type of system offers relative advantages, but DR may represent a better option for some facilities with a larger patient load due to the greater ease of use and elimination of cassette handling with DR, lower scan time, and less wear and tear on other key components of the equipment. A DR system is likely to have a similar footprint to an analog system and there will be a low probability of needing to remodel the X-ray space. However, purchasing a full DR system is far more expensive than adding a CR reader to the analog unit, which has deterred the buyers from switching to DR. This has spurred all the X-ray equipment vendors globally, to take an effort toward bringing the price of the DR systems down and maintaining the price for DR nearly twice that of a CR system.

Global Dynamics

The global X-ray equipment market valued at USD 8496 million in 2015, is poised to rise to USD 11,755 million by 2022, expanding at a CAGR of 4.71 percent from 2016 to 2022. X-ray devices market is the largest segment in medical imaging diagnosis market, with high adoption rate, market penetration, and being the most matured market in terms of technology and application.

Geography segmentation analysis. In 2015, North America accounted for the largest share of the X-ray equipment market and is expected to project standard growth over the next six years. The key driving factors are aging population, high adoption rate for equipment with innovative technology, rising public awareness related to diagnosis, and increasing number of research activities to develop new and advanced digital X-ray products. The market for diagnostic imaging and informatics is shifting as pathology and point-of-care diagnostics are providing in-depth insights into patient's condition than earlier. Market stakeholders positioned in the X-ray market are equipped with a unique portfolio to generate absolute and integrated solutions for definitive diagnosis.

Product segmentation analysis. The portable X-ray devices have high adoption rates due to their usability in ICUs and emergency departments with ease. One of the major advantages of portable X-ray equipment is that it reduces the risk involved in patient transfer from the designated unit to the radiology unit. Thus, the preferences of medical practitioners are rapidly shifting toward application of portable X-ray equipment due to its several advantages over stationary X-ray equipment.

Technology segmentation analysis. Technological advancements have introduced novel and superior X-ray systems that are found in applications such as detection of tumor outgrowths, breast cancer imaging, and several other chronic disorders and diseases. The demand for advanced systems is swiftly rising for early diagnosis to ensure efficient treatment and/or management of the disease. The recent technological developments in the diagnostics field have led to the market introduction of several highly developed X-ray systems such as CMOS and CCD-based digital systems, direct and indirect flat-panel-detection-based systems, direct digital radiography systems, and mobile and handheld digital systems.

A number of factors such as rising prevalence/incidence of cancer and cardiac, neurological, and musculoskeletal disorders; rise in awareness for early diagnosis; and growing number of diagnostic imaging procedures have increased the demand for imaging systems in healthcare facilities across the globe. However, a few market challenges such as achieving competitive advantage in such a mature market are difficult for new market players and high costs of advanced devices could result in lower adoption rates. Moreover, existence of large population with unmet needs in most of the emerging economies of the world would continue to provide future opportunities for the growth of the market over the next six years.

Industry Speak
Transforming CR to DR Systems

Radiography is a field that is marked as one for constant technological advancements and innovations, where different radiological equipment is developed to address the needs of various healthcare facilities and their patients.

The medical use of digital X-rays has become a common feature today when performing examinations such as mammograms, orthopedic examinations, and also dental scanning. Technological advancements in digital radiography arena have increased given the passion with which most medical institutions have involved the use of X-rays in performing several diagnostic procedures amongst patients. The benefits of using advanced X-ray equipment are many especially for healthcare practitioners who want point-of-care images of their patient's condition while they are performing diagnostic activities.

In addition, Asia-Pacific countries such as India, China, and South-East Asia are the emerging regions for radiography equipment due to economic growth and increasing attention of Asia-Pacific governments for the development of healthcare infrastructure. Additionally, India is focusing on investing in advanced and new medical imaging equipment. Thus, this factor may eventually stimulate the market growth of X-ray equipment. Advancement in technologies in radiography equipment will drive the market growth.

Fujifilm is one of the major players in diagnostic equipment with a wide range of X-ray, mammography, endoscopes, and medical IT software utilizing the medical imaging technology. Fujifilm is proud to have such range of medical equipment that aids early detection of lung, stomach, colorectal, and breast cancer, thus saving lives. In India, Fujifilm's computed radiography system has a 50 percent share. The company is also focusing on the full field digital mammography (FFDM) market and taking proactive steps to improve the early detection rate by conducting symposiums and spreading awareness.

The company has developed and provided new products and services, especially DR and healthcare IT (HCIT), focusing on expanding healthcare business in India. We are looking forward to this year as a new milestone for great growth with digitization of X-ray rooms in small towns and villages by transforming high-throughput CR systems to DR systems and installing FFDM at cancer institutes and medical colleges.

Chander Shekhar Sibal
HOD Medical Division,
Fujifilm India Private Limited

Planning for Upgrades

After the initial upfront investment in equipment, DR provides numerous advantages over CR, including better image quality, faster processing times, potentially lower radiation doses, and gains in productivity.

The most striking difference between CR and DR as imaging modalities is efficiency. Instead of previous X-ray methods that required the technologist to physically remove the film or cassette and carry it over to a processing area, DR technology captures the image directly onto a flat panel detector. DR images are available for review seconds after the image is taken. Being able to retrieve and render captured images on the spot allows for a more productive radiology workflow. DR reduces the processing time by anywhere from 90 to 95 percent. The quick turnaround increases workflow efficiency within the radiology department and results in time savings and as a result cost savings. With fast and efficient DR technology, facilities can see more patients. Higher utilization of their assets also translates into a higher reimbursement rate.

Industry Speak
Trends in X-ray Imaging Equipment

Although X-ray imaging equipment has been in widespread clinical use for a few decades now, it have been evolving in big leaps in several key dimensions; specifically top image quality at low X-ray dose as well as enhanced ease of use. Improvements in these dimensions are being realized across the clinical application spectrum of X-ray imaging in fixed and mobile diagnostic radiography, interventional fluoroscopy, as well as computed tomography.

Most of these improvements have been made possible by technological advances in:

X-ray generators. Sophisticated power electronics and digital controls have come together in creating high-frequency DC X-ray generators. These enable the control of X-ray acquisition technique parameters and exposure duration to an extraordinary level of precision resulting in minimal scattered X-rays that reduce image noise. This also results in optimal X-ray dose all of which contributes to imaging.

Flat-panel detectors. The technology behind radiographic and fluoroscopic flat-panel detectors has seen big leaps enabled by the high manufacturing-process yields used in the processes common to commercial flat-panel displays. Flat-panel detectors with pixel count of 16 mega pixels and pixel pitch as small as 100 microns are now able to create HD-quality X-ray images of very-high-spatial and grey-level resolution. The sensitivity and dynamic range of these detectors are superior to film and CR plates enabling the use of a much lower dose for acquisition. In addition, these flat panel detectors yield a diagnostic quality image over a wide range of technique factors enabling ease-of-use of the X-ray imaging device similar to a point-and-shoot camera.

Image processing software. Today, software image-processing algorithms have matured to a point that can autocorrect for many deficiencies at the time of acquisition - they can rebalance and enhance contrast, sharpen edges and features, remove noise and even act as virtual anti-scatter grid. In addition, advanced functionality such as automated image stitching, digital subtraction angiography, dual-energy chest radiography, respiration or ECG gated acquisition enables sophisticated clinical investigations and perfusion studies.

Size, weight, and portability. The form factor of most imaging devices has morphed to become smaller and lighter, enabled by advances in capabilities of electronic components in handling power and heat with increased processing power. Control consoles have become integrated and enabled by touch-screens that can be used for setting as well as viewing the acquired images. Mobile systems have become much more maneuverable. Some models are equipped with batteries and have the capability to acquire hundreds of X-rays from a full charge, thus avoiding use of lengthy cables to the closest wall power socket.

With the potential applicability of Internet-of-Things and cloud-based wireless technologies used in commercial electronics industry in medical imaging devices, we are sure to see even more disruptive exciting devices at competitive cost.

Sanjay Bharadwaj
Chief Architect-Advanced Technologies,
Skanray Technologies Private Limited

There are other benefits of DR. Not only does the technology eliminate the need for costly film-processing steps, but it carries the potential for radiation dose reduction. Imaging quality is also improved, with a wider dynamic range that makes it more forgiving for over- and under-exposure. Technologists can use DR system software to apply special image processing techniques that enhance overall display of the image, helping radiologists make better diagnostic decisions. One of the downhill effects could be a more satisfying patient experience, a metric that many facilities would like to improve.

The benefits of DR are widely recognized by the medical imaging community, but adoption has been slow for some because of the challenge of finding cost-effective ways to upgrade or replace their existing technology.

Second Opinion
Digital Radiography - A Game Changer

Digital radiography (DR) is now an inescapable asset in any radiology set up with a steady gain in popularity. Present-day imaging systems provide a high-quality image with minimal radiation exposure. DR has this capability and further advances will possibly lead to lowering the radiation dose and using higher-sensitivity plates to give good resolution and sharpness to images. Portable radiography is another significant reason to adopt DR.

Today the images from radiography and imaging systems can be flashed across the globe in split-second speeds, enabling physicians to advise and manage any medical challenge and ensure excellent medical outcomes.

Key challenges that healthcare organizations need to consider are regulating and minimizing radiation dose and compact radiography systems that can be used anywhere and at any time with least power consumption. Easy and effective integration of image archiving, storage, and easy access to the physician must be ensured with least delays and technology snarls. At the same time, patient's confidentiality and privacy of information has to be considered when disseminating data across the globe.

The important advantage of digital imaging is cost and access. Advantages of digital imaging are immediate availability of images to referring physician, reviewing previous images, lower film cost, reduced requirement of storage space, and lesser staff required to run the services.

Flat-panel CR is another technological advancement. The yield of electrons is five times as compared with CR and it gives a superior image quality and dose efficiency.

Solid-state flat panel DR provides better quality than CR or SFR and at the same time requires a lower radiation dose. In the newer DR versions, amorphous selenium has replaced photo sensors. The clinical utility of these recent developments is immense and the overwhelming advantages offered by these newer modalities will lead to their widespread use.

Filmless radiology departments are the way to go and most large hospitals in the corporate sector have adopted the systems leading to revenue saving. Better detectors, faster processing, more powerful computers, bigger and sharper displays, and efficient archiving are transforming the way we look at medical imaging. Higher-grade medical viewing monitors provide excellent image quality. The PACS has enabled integration with the radiology information system and electronic patient records and will transform medical care and be a valuable help to patient's outcomes during their stay in hospital and even after being discharged.

Dr Dinesh Kapoor
Director & HOD of Radio Diagnosis,
Fortis Healthcare

Manufacturers of DR systems are responding to these challenges by creating attractive programs and product packages that help facilities make the transition to digital affordable and with minimal interruptions in workflow.

Because of budget cycles, most imaging facility administrators are currently in the planning stages of upgrades. One of the first considerations is the facility's current space. What needs replacing and what could remain for a few more years? Will the whole room need to be replaced? Some facilities will have one or two rooms to upgrade, while others will have dozens. For larger health delivery networks with multiple sites, putting together a strategic plan will help hospital administrators outline how to go forward. If those plans include construction, the room could be offline for several months. Organizational leaders may also need to consider changing the room's configuration to better 
accommodate workflow.

Second Opinion
Evolution of Diagnostic Imaging equipment in India

There is a rapidly increasing demand for diagnostic imaging equipment in India. As health awareness is fast growing in parallel with education standards, the market size has been fast increasing. Over the recent past, technology has stepped up multiple notches in healthcare, which implies that today we are equipped to manage more volume and complications better than ever before.

The market supply is fast pacing with demand, with ever-newer players entering the market. The Indian market seems to exhibit significant market fragmentation because of its unorganised nature, which leads to more competitively aggressive market pricing. In a closer look over the industry over the last 20 years, we can notice that with respect to the fast-pacing supply growth along with fragmentation, the customer-end market prices have not increased in comparison to an increase in input costs.

Unlike most other industries, healthcare will exhibit near-zero correlation with recessions, but display a strong correlation with extremities in weather and during holiday periods. As especially visible in northern part of the country, demand tends to deviate significantly with extremity in weather, and during public holidays.

Healthcare - Sometimes a Need, Sometimes a Want

As can be inferred from the seasonal dependency, a considerable portion of market does depend on customer discretion for the demand of services. This segment may choose healthcare, for example, for evaluating a minor knee joint pain, only if severity of the situation increases or prices are found reduced to a level whereby it becomes relatively insignificant in comparison to his/her purchasing capacity.

On challenges and opportunities. Market fragmentation and its unorganized nature pose the most significant challenge as this result in a spiral down of prices. This also forms the most significant opportunity for a key player to view this challenge as a stepping stone.

On buyer's perspective. The need of the hour is technology availability at a cost-effective pricing, which is a market-driven factor based on volumes and pricing established in various markets. Any model which is based on cost effective purchase in the right market will succeed.

On future outlook. With the Make in India initiative, if the equipment starts getting manufactured in the country instead of being imported, lower-cost equipment can be manufactured. Anyhow, this recession-free market is very promising if approached with caution and with right strategy.

Dr SK Sogani
Chairman-House of Diagnostics,
Indraprastha Apollo Hospitals

Replacing the entire X-ray room is not the only option, however. For some facilities, upgrading existing CR technology can allow them to make the shift to DR without major upfront costs.

From a staff workflow perspective, converting to a new DR system poses few training hurdles, since many of the software platforms available are already familiar to technologists. Rather, the biggest challenge for most facilities is securing the capital funding to pay for the system, which manufacturers say they can offset by using customizable, vendor-neutral solutions. Agfa, for example, offers a program called Fast Forward DR that allows the company to provide a unique cost structure, such as monthly payments only marginally higher than those a hospital currently makes to maintain its prior CR technologies. The efficiencies gained by the new technology help the system pay for itself.

Innovations in X-ray imaging technology have come a long way, and with more hospitals adopting digital technology, the field will continue to benefit from improved image quality, reduced radiation dose to patients, and a more efficient workflow. Making the conversion to more efficient DR technology allows healthcare organizations to keep up with ever-changing healthcare regulations as well as maximize returns on their imaging investments.


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