Remember when Caparsolate was used to treat heartworms? When halothane was the most common inhalant anesthesia? Or when X-ray film was developed by hand-dipping a metal frame into tanks of solution in a darkroom, then hanging it to dry?
New veterinary graduates may have to Google “Caparsolate” and “halothane,” and in the near future they may have a hard time finding a veterinary practice that still develops X-ray film.
Digital radiography, which eliminates the darkroom, chemicals and manually filed plastic film, moseyed into veterinary medicine in the early 2000s, hit its stride around 2004, and today is galloping full-tilt into mainstream use.
“The technology has gotten better, the software has gotten better and the prices on the client side have gotten better,” said Seth Wallack, DVM, Dipl. ACVR, who practices in San Diego. “The time of the early-adopter of digital is over, and now it’s more mainstream. It’s becoming the norm.”
Digital technology is much faster than conventional radiography, and the software allows adjustment of brightness, contrast, zoom and pan on a single exposure. As long as the patient is positioned correctly, most everything else can be fixed by the machine’s controls.
“Digital radiography offers better latitude and contrast than the traditional method,” said Laura Armbrust, DVM, Dipl. ACVR. “You have fewer retakes. It’s more user friendly in terms of setting exposure technique.”
Techniques are simplified, noted Greg Stoutenburgh, vice president of marketing and advanced modalities with software giant Sound-Eklin of Carlsbad, Calif.
“Tools are built into the software that show the technician what the radiograph should look like if the animal is positioned right and the radiograph is hung properly,” Stoutenburgh said.
Dr. Armbrust, an associate professor of radiology at Kansas State University’s College of Veterinary Medicine, said a multitude of digital X-ray products are available, most of which can be incorporated into a practice’s existing equipment.
The two categories of digital radiography are computed radiography (CR) and direct radiography (DR), explained Penny Guyton, director of marketing CAG Digital with IDEXX Laboratories Inc. in Westbrook, Maine.
Computed radiography allows practices to retrofit existing equipment by replacing standard film cassettes with a CR cassette that contains a reusable imaging plate. After the X-ray is taken, the cassette is placed into a scanner that digitizes the image and sends it to a personal computer for display.
With direct radiography, the plates are built into the bucky table, Guyton continued, and its advantage is that a technician doesn’t have to manually transport the cassette from the bucky table to the scanner because the machine does it automatically.
In either case, “Both technologies are capable of producing very good image quality,” she said. “The price of DR is higher than CR, however, so larger hospitals or those with higher X-ray volume are more likely to purchase DR, where they can achieve a faster return on investment because of its workflow advantages.”
IDEXX sells twice as many CR systems as DR, Guyton said.
Digital radiography has “absolutely” become more affordable, she said. One bonus is that a current X-ray machine, if the generator works well, can generally be calibrated and used with a CR or a DR system, she said.
Options are available for “scalable, entry-level CR systems that can grow with a practice,” Guyton said.
“Many clinics find that having digital radiography changes their practices in ways that they hadn’t anticipated, because the image quality is so superior to film,” she noted.
Sound-Eklin’s Stoutenburgh said that because of the way digital data is stored, veterinarians can “forget about per-shot” when doing a radiographic series, such as on an elbow. If cranial-caudal, lateral extended, and lateral flexed views are needed on both elbows for comparison purposes, an elbow study may be ordered via the computer, which keeps track of the views.
“By ordering X-ray studies instead of individual images you are able to practice medicine in a way that is better, more consistent and more profitable,” Stoutenburgh said.
Armbrust, of Kansas State, noted that digital radiography has revolutionized field service calls because the results are immediately visible, saving the veterinarian from having to return to the clinic to develop the films.
Digital images can be stored onsite, in a remote location or both. Considerations include an ability to readily retrieve the X-rays, maintaining the privacy of medical files and protecting against disasters such as fires or floods.
“Today’s cloud storage backup options reduce the requirements of staff and local hardware to manually perform backups, and by nature of the technology, provide comprehensive disaster recovery as well,” Guyton said.
Cloud computing technology provides a common network that can communicate data to different online sources: laptops, cell phones, iPads and more.
Digital X-rays stored in a cloud can be accessed “anywhere in the world, as well as shared via a link sent by email to colleagues or the client,” Stoutenburgh said. “Or a click by email sends it for an overread and report by a board-certified radiologist.”
Armbrust said most digital equipment is user friendly, and a manufacturer usually provides training with the purchase. Meanwhile, in her classroom, students receive instruction in both traditional and digital radiography.
“I always ask for a show of hands on how many students have worked with digital radiography,” she said.
Five years ago, about 10 percent of them responded. “Now,” she said, “it’s about 50 percent.”
DR Devotees: No Regrets
Two veterinarians who converted to digital radiography now readily spread the gospel.
“It’s so convenient that I took more radiographs in the first eight days I had it than I did in the previous three months,” said Mark Purser, DVM, owner of Highland Knolls Veterinary Hospital in Katy, Texas. “The biggest benefit is you get significantly better diagnostic images. Unless you’ve got a bad position, you don’t have to do retakes.”
For David Colton, DVM, “It’s amazingly effective at taking really high-quality X-rays. What we’re finding is the technician-time is so much quicker.”
An owner-partner in Central Oregon Veterinary Group in Bend, Dr. Colton said late-afternoon radiographic studies that he formerly put off until the next morning are now handily accomplished by the close of business.
In deciding whether to go digital, Dr. Purser put pencil to paper.
“I calculated that it was costing me $350 a month for film, chemicals and upkeep on a processor, while we could put in a digital system for $700 a month and own it after five years,” he said. “Yes, it doubled how much it cost me, but it was a matter of $700 for five years versus $350 forever, and the quality, ease and convenience are so much better.”
Highland Knolls is a 21/2-doctor practice serving 5,000 patients.
Colton’s practice in Oregon includes a one-doctor clinic and an older, two-doctor building where the digital system was installed.
“We have a very old, ’60s-era X-ray machine and we had it recalibrated,” he said. “We put a DR system in, where we took out the bucky and installed a DR plate.”
Digital radiography was a part of the building’s overall remodeling plan, he said. Rather than equipping each exam room with a computer, the clinic uses a wireless computer network, or Wi-Fi, and a single iPad to display the digital X-rays.
“Literally, their mouths will drop open,” Colton chuckled about his clients’ reactions to what they experience.
“When people walk into an older building, they expect to see an old doctor standing there in suspenders, and then we walk in with this technology,” Colton adds. “It really raises the bar for us.”
Colton, who does a lot of knee procedures, sends home pre- and post-op images with the clients.
“It definitely increases the perceived value of what we’re doing,” he said.
Purser said his digital equipment fits well with the clinic’s veterinary computer software. The digital data is backed up nightly, he said, and “we never have to worry about finding a radiograph.”
At Highland Knolls, clients are shown the digital images on an iPad and given a compact disc to take home.
“It looks a whole lot more impressive than sticking a piece of plastic film up on a view box,” Purser noted
The cost to clients was small, Purser said.
“We weren’t cheap beforehand, so we didn’t significantly go up in price,” he said.
Stumped? Try a Teleconsult
If the sky ever was the limit for radiologist Seth Wallack, DVM, Dipl. ACVR, his teleconsulting computer platform just moved him a little closer.
Dr. Wallack said he started his Vetology teleconsulting platform in October “to help other independent radiologists run their business.”
“We’re helping move images from veterinarians to radiologists, and their reports back to the veterinarians,” he explained, “and we’re doing it in a way that’s revolutionary.”
In 2005, Wallack opened the Veterinary Imaging Center of San Diego, a stand-alone outpatient facility focused solely on imaging: X-rays, ultrasound, computed tomography, magnetic resonance imaging, nuclear medicine, teleradiology and interventional radiology. The center’s specialists also perform feline radioiodine therapy for hyperthyroidism.
He has published professional articles and book chapters, and in 2007 he started the American Association of Veterinary Radiologists.
For him, “It’s not just about images any more. We’re incorporating every aspect of a patient’s medical record into the consult and getting it into the hands of the consultant,” he said.
A typical package might include radiographs, blood work, histopathology and an ultrasound video.
The teleconsulting market is maturing along with digital imaging.n>
“The veterinarians who embrace the Internet are going to realize very quickly that they can have specialists from all over the world advising them,” Wallack said. “They can have the very, very best right at their fingertips, through the computer screen.”
The cost of a teleconsult depends on the case, he said, but should be less than the time and expense to the client of a referral to a board-certified specialist. Using Vetology, “I predict the cost of a specialist consult will be $120 to $130 out the door to the client, which means the veterinarian’s cost would be even less,” Wallack said.