Director’s Circle: X-Ray

ICE Magazine invited imaging leaders to participate in this month’s Director’s Circle feature on X-ray technologies in diagnostic imaging. Topics touched on in this discussion include the latest technology, how to evaluate systems, dose reduction and more. Participants in the article are:

• SSM Health, St Louis Regional Service Line Director of Imaging Jessica Chambers;

• University Hospitals Radiology Director, West Market Michelle Dossa;

• Hartford Hospital Imaging Director Sandra Smith Phillips;

• Oklahoma City Indian Clinic Director of Radiology Lisa Walling; and

• AdventHealth Director of Ambulatory Imaging and Imaging Safety Program Cory Whitehouse.

Q: HOW HAVE X-RAY TECHNOLOGIES EVOLVED IN RECENT YEARS, AND WHAT ADVANCEMENTS ARE HAVING THE GREATEST IMPACT ON CLINICAL WORKFLOWS?

CHAMBERS: The shift to the digital platform continues to advance, while I would assume most everyone has converted from CR to DR the AI and dose optimization tools that are coming with the digital technology is impressive. From enhancements to line placements to pneumothorax algorithms, these new technologies will both improve efficiencies within our departments and, most importantly, outcomes for our patients. I also appreciate the attention to detail the OEMs have with workflows and body mechanics; detectors 10 years ago were heavy and difficult to move. I feel each year the imagine quality improves as well as the ergonomics to move them and weight. 

DOSSA: AI has truly improved the images/care we can give our patients with self-calibrating systems and units that flag maintenance issues as well as predictive analytics for early disease detection and smart triage AI to prioritize imaging cases for our radiologists. The automation that X-ray equipment has in setting up for image views is something I never had as a technologist that can be used to make our techs as efficient as possible.

PHILLIPS: X-ray technology has shifted toward digital radiography (DR) as the standard, offering faster image acquisition and improved image quality. Recent advancements include wireless detectors, mobile systems and integrated workflow automation that reduce manual steps. AI-driven tools for image enhancement and positioning guidance are also streamlining processes, minimizing retakes and improving throughput.

WALLING: The use of automation – such as auto-positioning, auto-exposure and protocol-driven workflows – has improved exam turnaround time and improved consistency. 

WHITEHOUSE: One of the most significant advancements in recent years has been the widespread adoption of digital radiography (DR). DR technology has dramatically improved efficiency by reducing radiation exposure and minimizing the need for repeat exams, which enhances patient safety and throughput. Additionally, DR systems provide faster image acquisition and immediate availability for interpretation, streamlining workflows and improving diagnostic turnaround times. However, an unintended consequence is that technologists may rely heavily on system automation, potentially reducing their proficiency in manual technique selection. This underscores the importance of ongoing education and competency training to maintain high standards of image quality and patient care

Q: WHAT FACTORS SHOULD IMAGING LEADERS CONSIDER WHEN EVALUATING NEW X-RAY SYSTEMS FOR THEIR FACILITY?

CHAMBERS: I oversee seven hospitals and multiple outpatient centers, and it’s easy to get caught up in the desire for the latest and greatest technology. However, with declining reimbursements and rising levels of bad debt and charity care, we must be good stewards of our resources. The priority should always be leveraging your organization’s identity to ensure you have the best technology for your specific patient population. You may not always need the newest AI feature if it significantly increases costs without clear benefit. As imaging utilization continues to grow, dose reduction strategies remain top of mind. Beyond that, decisions will vary based on each hospital’s unique needs and operational priorities.

DOSSA: As an organization that has a 10-year equipment non-obsolescence plan with OEMs, we work closely with our vendor of choice for X-ray. A team of key stakeholders (radiologists, technologists, physicists, rad IT, HTM, leaders, strategy, supported service lines, i.e., oncology, cardiology, ortho, etc.) worked together with the OEM to review available fleet, software options, AI capabilities, dose optimization capabilities, and what may be on the horizon when developing our equipment configuration plan. We have a general equipment configuration for stationary X-ray, fluoroscopy, portables and C-arms based on location (academic hospital, community hospital, ambulatory site). We strive for consistency for patient access and staffing flexibility, the ability to properly provide clinical support for existing and future caregivers/service lines over the course of multiple years. 

PHILLIPS: Imaging leaders should consider:

• Staff engagement: Involve technologists early – they are the primary users. Conduct demos with subject matter experts.

• Volume and case mix: Choose equipment that aligns with your patient load and exam types.

• Mobility: For portable systems, prioritize ease of use and consistent image quality.

• Advanced features: Look for positioning assistance, workflow integration and AI tools that enhance efficiency and image quality.

• Dose optimization: Select systems with advanced dose monitoring and reduction technologies.

• Interoperability: Ensure seamless integration with PACS/RIS and EMR systems.

• Service and maintenance: Review service contracts and preventive maintenance options.

WALLING: Leaders need to analyze their facility’s demands and staffing realities when evaluating new systems. Things to consider are the types of cases (trauma, orthopedic or bedside), how the system can enhance workflow efficiency, dose management, flexibility of the system and cost.

WHITEHOUSE: Cost is always a consideration, but decision-makers should prioritize value and long-term ROI over initial price. Key factors include compatibility with existing RIS/PACS infrastructure, scalability for future upgrades, and flexibility to support multiple clinical applications. Mobile DR units can be particularly advantageous, enabling bedside imaging and improving access for patients with limited mobility. Leaders should also assess automation features, dose optimization capabilities, and integration with AI-driven tools to enhance positioning accuracy and workflow efficiency. Ultimately, the goal is to select systems that align with organizational strategy and deliver both clinical and operational benefits.

Q: HOW ARE FACILITIES BALANCING RADIATION DOSE REDUCTION WITH THE NEED FOR HIGH IMAGE QUALITY, FASTER THROUGHPUT AND DIAGNOSTIC ACCURACY?

CHAMBERS: This really is the million-dollar question. In my opinion, the best solution is to move toward a truly quality-focused reimbursement structure rather than a per-click model. We continue to see imaging utilization rise. Our emergency department imaging volumes are growing even though overall emergency department patient volumes have not. This highlights that it’s imaging utilization, not patient visits, that’s increasing. A few years ago, CMS explored appropriateness criteria for imaging, but unfortunately, that initiative has fallen by the wayside. I believe organizations need to dive deeper into utilization as the first line of defense for improving throughput and reducing dose. From an operational standpoint, I feel our organization is already as lean as possible; expecting staff to simply work faster is not a sustainable solution. We need to shift the focus from quantity to quality.

DOSSA: Our in-house medical physicists participate in our equipment non-obsolescence planning and guide us with dose reduction needs. It needs to be a balance to ensure quality imaging, efficient patient throughput and appropriate radiation dose for our patients. Taking a quality image the first time versus repeating is another great way to reduce dose, so ensure your technologists are part of the equipment process. They need to have an easy-to-use piece of equipment that allows them to be as efficient as possible given the heavy demands on their time and talents.

PHILLIPS: At Hartford HealthCare, we brought our imaging and radiation safety team in-house. This enables real-time support and stronger collaboration with technologists, radiologists, oncologists, physicists and patients across our system. The team oversees dosimetry and dose-reduction tracking software, monitoring performance consistently to improve communication and achieve meaningful dose reductions without compromising image quality or efficiency.

WALLING: Facilities are leveraging smarter technology to help with dose reduction. Advances in detector sensitivity and better image processing are allowing lower doses. Ongoing technologist education and dose monitoring programs are critical – allowing departments to identify outliers and continuously refine protocols without compromising image quality or speed.

WHITEHOUSE: Modern DR systems have been instrumental in achieving this balance. They allow for significant dose reduction while maintaining diagnostic image quality through advanced detector technology and image processing algorithms. Facilities are leveraging protocol optimization and software-driven exposure controls to ensure consistency across exams. Additionally, continuous monitoring of dose metrics and adherence to ALARA (As Low As Reasonably Achievable) principles remain critical. These strategies collectively support patient safety without compromising throughput or diagnostic confidence.

Q: WITH THE RISE OF AI-ASSISTED POSITIONING, WORKFLOW AUTOMATION, AND IMAGE ENHANCEMENT TOOLS, HOW IS AI SHAPING THE FUTURE OF X-RAY IMAGING?

CHAMBERS: I believe AI tools are significantly improving image quality while helping to standardize workflows. They provide an added level of confidence for newer technologists by having protocols programmed directly into the equipment. Reducing cognitive burden not only enhances efficiency but also helps manage workload across teams. Even small improvements, like reducing the number of clicks per exam can add up to meaningful time savings in the long run.

DOSSA: AI is a tool that we use to support our diagnostic imaging. We want our technologists to be working at the top of their licenses, so if there are tasks that AI can support so they can, that is the very best. AI tools showing lines, pneumothorax, etc. are helpful for techs and radiologists as well.

PHILLIPS: AI is transforming X-ray imaging by reducing variability and improving efficiency. Positioning guidance minimizes retakes, while automated workflow orchestration accelerates exam completion. AI-driven image enhancement improves clarity for faster interpretation, and predictive analytics help optimize equipment utilization. In some cases, AI even supports staffing shortages by enabling remote technologist assistance.

WALLING: AI-assisted positioning and collimation reduce repeats and variability, while automated image quality checks flag issues before the patient leaves the room. AI-based image enhancement improves visualization in challenging patients and reduces retakes. Over time, these tools will help address staffing shortages, support less-experienced technologists, and create more standardized, reliable imaging across sites.

WHITEHOUSE: AI is poised to transform X-ray imaging by reducing variability and improving efficiency. While adoption of AI-assisted positioning is still emerging, these tools can significantly benefit less experienced technologists by guiding patient alignment and minimizing repeat exposures. AI-driven workflow automation – such as intelligent exam routing and predictive scheduling – can streamline operations, while image enhancement algorithms improve clarity and diagnostic accuracy. As these technologies mature, they will play a pivotal role in standardizing quality and optimizing resource utilization across imaging departments.

Q: WHAT COMMON MAINTENANCE OR QUALITY ASSURANCE ISSUES SHOULD IMAGING LEADERS MONITOR TO KEEP THEIR X-RAY FLEET PERFORMING OPTIMALLY?

CHAMBERS: I would say my number one pet peeve is dropped detectors. While the advancements in detector technology over the years have been incredible, the downside is that the more advanced they are, the more expensive they become. Nothing is worse than starting the day and hearing from the morning tech that a detector won’t associate because it registered a drop. With any high-cost piece of equipment, preventive maintenance is critical, along with implementing safeguards to ensure staff handle the equipment properly and avoid unnecessary damage.

DOSSA: Our radiology leaders work closely with our HTM leadership and teams on the ground that support our imaging equipment. We all participate in quarterly business reviews with each vendor in an effort to ensure our equipment is working as intended and its producing quality images throughout its expected life cycle. Our HTM team performs some preventative maintenance and/or first looks for specific modalities while we choose to have other modalities serviced by OEMs. It is not an all or nothing strategy and has helped build the relationships between our HTM teams, our OEMs and our medical physicists. Ensuring PMs and QAs are performed per manufacturers’ recommendations is critical. Setting up PMs in the beginning of the year versus on the fly is incredibly helpful to the technologists and patients. We never want to be the reason a patient is rescheduled. Ensure a solid workflow for notification and escalation of equipment issues. Ensure everyone is aware of the process and review throughout the year. We have found that it works well versus waiting for an issue to come up and the technologist is unsure of the process.

PHILLIPS: Regular calibration, detector checks, software updates and preventive maintenance are critical. Leaders should track image quality trends, dose reports and system uptime to identify issues early. Compliance with regulatory standards and maintaining technologist competency in QA protocols are essential. Having in-house physicists greatly enhances preventive maintenance and testing capabilities.

WALLING: Some key areas to consider are detector performance, tube output consistency, alignment and collimation accuracy, and software updates. Wireless detector handling and battery health are frequent pain points. Leaders should also monitor repeat/reject rates, exposure index trends and downtime patterns. A proactive QA program – combining routine physicist testing, technologist feedback and vendor service data – helps prevent small issues from becoming costly disruptions.

WHITEHOUSE: Here at AdventHealth, we have a robust quality assurance (QA) program. Facilities should implement systems to track retake rates, monitor equipment performance and identify technologists who may require additional training. Routine preventive maintenance, calibration checks and software updates are critical to sustaining image quality and minimizing downtime. Data-driven QA programs not only ensure compliance with regulatory standards but also provide actionable insights for continuous improvement.

Q: WHAT ADVICE WOULD YOU GIVE FACILITIES PLANNING TO EXPAND, REPLACE OR MODERNIZE THEIR X-RAY CAPABILITIES IN 2026 AND BEYOND?

CHAMBERS: I would start by ensuring you have a clear understanding of your organization’s strategic goals. Capital is often limited, so it’s important to invest in solutions that will meet your needs not just today, but for the next 5 to 10 years. Understanding your organization’s identity helps avoid unnecessary features while ensuring you have the essentials to succeed. AI can feel overwhelming right now. With it being so new, it’s easy to get caught up in the excitement of the latest technology, but it may not be necessary for your specific location. Instead, focus on partnering with an OEM that offers flexibility, one that can customize and scale with you over time without requiring major hardware purchases. Building a relationship with an OEM that acts as a true partner, rather than just a transactional vendor, can be a key factor in your long-term success.

DOSSA: It seems as if we are always in the process of expanding throughout our system. Having vendors of choice via a non-obsolescence replacement plan and established equipment configurations are significant improvements for us. Our vendors know what we need which makes quoting/selection process much easier and less time consuming. While it will take a few years to replace a lot of equipment, the standardization we have seen in 3 years is already paying off in patient care/access, staffing confidence/flexibility, HTM and physics efficiencies.  AHRA offers a white paper on equipment non-obsolescence planning that is incredibly helpful if your organization is interested in pursuing.

PHILLIPS: Engage stakeholders early – radiologists, technologists and IT – to ensure smooth adoption. Meet with vendors and conduct thorough research to identify solutions that fit your organization’s volume, throughput and financial goals. Visit other facilities to gather feedback from leaders and frontline staff. Finally, develop a strong business plan with a clear ROI, as budgets remain tight across healthcare organizations.

WALLING: Start with workflow and patient needs, not just equipment specs. Engage technologists early, standardize protocols across rooms and sites, and prioritize systems that support automation, AI-readiness and interoperability. Plan for flexibility – volumes, staffing models and clinical demands will continue to shift. Finally, think long-term: invest in platforms with clear upgrade paths and strong vendor support to ensure your X-ray fleet remains efficient, safe and future-ready.

WHITEHOUSE: Futureproofing your investment is key. Select systems that offer modularity and scalability, enabling upgrades without full replacement. Prioritize interoperability with RIS/PACS and consider mobile DR solutions to enhance flexibility and patient access. Evaluate vendors based on service support, training programs and technology roadmaps to ensure alignment with long-term goals. Finally, remember that lowest cost does not always equate to best value – focus on solutions that deliver durability, adaptability and clinical excellence.

This month’s article was sponsored by X-ray America. For more information on this company, visit x-rayamerica.com.

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