NEC MultiSync MD

Apparently, when it comes to medical equipment, bigger isn’t always better. More than ever, healthcare facilities – from hospitals and physician offices to freestanding diagnostic centers – are gravitating toward slimmer, more streamlined equipment that can pack a powerful punch in terms of quality, without encroaching upon valuable space.

One product, in particular, that’s getting a more scaled-down profile is the medical display monitor. To say that the bulkier cathode-ray tube monitor has, until recently, dominated in the healthcare environment would be an understatement. Market research shows that just five years ago, 95 percent of all monitors used in healthcare were CRT. In 2004, the U.S. medical display market, which included CRT and liquid crystal displays, was valued at $281.1 million. CRT monitors accounted for just 15 percent on a revenue basis, with the rest going to LCD displays, according to figures from Frost & Sullivan, the global growth consulting firm.

And that trend will only continue. Over the next several years, LCDs will likely account for 95 percent of monitors in healthcare, sources told Healthcare Purchasing News. In fact, some vendors say their current sales for LCD displays are already matching that figure.

"CRTs currently represent only five to ten percent of our total business. Just five years ago, they represented 90 percent of our business," said Todd Fender, product line manager for medical displays, NEC Display Solutions, Itasca, IL. He added that eight years ago, LCDs comprised less than 1 percent of NEC’s business. "Obviously, the market has shifted dramatically."

Indeed. The proliferation of LCD monitors has understandably led to a shrinking CRT market. Some standbys, such as the Trinitron CRT, have dropped out of production and others will likely follow suit as flat panel performance and pricing continue to improve.

"Flat panels are already becoming the norm. Within five years, CRTs will no longer be used," predicted Rob Gregory, senior product manager for Planar’s medical business unit, Beaverton, OR.

Plugging into savings
A number of key factors have spurred the shift away from CRTs; most notably, the significant drop in unit price for LCDs in recent years.

Today, LCDs, which once cost up to three times more than CRT monitors, are now comparable in price to what CRTs were three to five years ago. Lower production prices are also making larger screens more affordable. Fender noted that, today, a 46-inch medical grade LCD can now be purchased for what a 20.1-inch display cost just several years ago. Essentially, what was once little more than a coveted item on cash-strapped hospitals’ wish lists has now become a viable, cost-effective option.

But the cost benefits aren’t limited solely to the lower sticker price. LCD monitors require at least 75 percent less space than most CRTs and can reduce display energy consumption by approximately 60 percent. "An added benefit is that LCD panels generate considerably less heat," said Gregory.

Longer replacement times for LCDs are also attractive for healthcare organizations looking to maximize their investment. Frost & Sullivan reports that hospitals and medical centers typically replace a CRT monitor every three years (although careful maintenance has enabled some to last as long as five or six years). LCD monitors, on the other hand, have an average life cycle of five to seven years.

"The cathode ray tube can start to go out of tight specifications required for medical images significantly sooner than an LCD display," explained Katherine Shariq, senior industry analyst for Frost & Sullivan’s medical imaging group.

Ergonomics and improved visual performance also factor into the equation. Not only are visual search times for text targets embedded in a screen of text 22 percent faster for LCDs than CRTs, they are also faster for low contrast, small characters. What’s more, uniform screen brightness and a flexible surface screen covering lend itself to less glare, and the fact that LCDs are flicker-free means users will enjoy enhanced image viewing with less eyestrain.

Their lighter weight is another advantage because they can be easily moved around on carts or workstations, or mounted on an articulating arm or wall to increase floor space.

Razor thin, razor-sharp
Not surprisingly, image quality is the most important factor going into monitor selection, and the good news is LCDs offer exceptional performance.

Planar Dome C5i

"Flat panels are becoming brighter with better resolution, higher contrast capabilities and response time. In the next few years, we will wonder why anyone is still using CRTs," noted Chris Bowman, director of communications for Irvine, CA-based Ampronix Inc. "The actual image trueness – data captured to data displayed – is already a quantum leap forward."

Flat panel monitors feature a flat matrix display where every pixel is active, so there’s no worry of geometric image distortions at the screen edge. Also, no image loss at the boundaries means an LCD can provide a full two inches more viewing area than a CRT (a 17-inch LDC, for example, will offer the viewing area equivalence of a 19-inch CRT).

"Faster panels, along with better viewing angles have also increased [LCDs’ appeal]," explained Ron Hansen, product manager for
National Display Systems (NDS), Morgan Hill, CA.

LCDs provide higher brightness and resolution than most CRTs, which allows for a much crisper image and enhanced focusing capabilities. Their display images are also more stable. CRT displays tend to drift out of focus rather quickly and require regular calibration; any drift that occurs on an LCD, however, can be easily fixed with a new backlight. LCDs also do not require analog/digital conversion when transmitting digital images.

"Their digital signals make it easier to integrate the monitors into a standard local area network for data transmission and remote maintenance," Shariq said.

While manually calibrated diagnostic LCDs cost less, numerous vendors – including Barco, Planar,
Image Systems, NEC Display Systems and Siemens — offer automatic calibration solutions to simplify the process and ease administrative burdens.

"The DICOM calibration and remote management software provides the ability to monitor multiple – even hundreds – of displays within an enterprise for correct operation and DICOM calibration," Gregory explained. Automatic calibration solutions not only ensures DICOM conformance through backlight stability verification, they also document the time the display was tested and any adjustments made, which makes record-keeping a snap.

[Note: Medical imaging experts generally still recommend routine calibration of both CRT and LCD displays to remain DICOM compliant and ensure imaging accuracy.]

Where flat makes sense
Given the wide array of benefits offered by LCDs, its little wonder so many healthcare departments have made the conversion. Today, LCDs can be found at the patient’s bedside, making it easier than ever for caregivers to access and input patient information, and in nurses’ stations, diagnostic departments, surgical suites or anywhere else in the healthcare environment where space is limited and top quality viewing is a must.

"Minimally invasive surgery is well suited for flat panel displays, as are radiology reading stations," noted Hansen. "[And because of] their low power requirements, portable and mobile equipment, such as ultrasound, are also well suited to flat panel displays."

Research from Frost & Sullivan underscores the flat panel trend in diagnostic and picture arch-iving and communications system applications.

"The shift away from analog CRT display monitors to digital data capture and display has already occurred in diagnostic PACS workstations, and for the other imaging modalities – particularly ultrasound – [they’re] likely to be completely converted to LCD displays in a few years," Shariq noted. She said medical imaging acquisition and diagnostic referral displays accounted for more than two-thirds of the market in 2004; the remaining one-third of the market favored displays used in patient monitoring applications over those used strictly for surgical procedures.

Still, the demand for high-resolution, flat panel displays among surgeons and emergency department physicians is expanding. In particular, surgical teams are skipping the CRT phase altogether and moving directly from films to LCDs as a way to see crisp, clear MRI and CT images, according to Shariq.

In spite of the apparent benefits of LCDs, they may not be suitable for every area of medical imaging. "Flat panel displays and monitors may not be appropriate for areas that require high-frame rate applications, such as kinetic imaging in the cath lab," noted Rik Primo, director of marketing and strategic relationships for Siemens Medical Solutions USA Inc.

Gray matters
When shopping for LCD monitors for diagnostic applications, sources agreed that the way the units render grayscales and black levels is critically important, as is the way they hold brightness, contrast and the white point. The white point refers to a color of light emitted by a light source.

"With better densities and lows (blacks) and better, brighter highs, the mid-range stretches out. And with the ever-evolving higher mega pixel count resolution technology, LCDs can’t help but surpass the old style projection tubes pretty quickly," said Bowman. "We are already seeing 9.2 mega pixel LCD displays, which far exceed CRT resolution."

Anatomical details are hidden in grayscale levels. As Primo explained, "the better the contrast [between black and white], the more ‘grays’ can be perceived to the human eye, allowing a doctor to better discriminate anatomical detail." He noted that today, flat panels have a ratio greater than 500:1. For comparison, home televisions have contrast ratios of approximately 250:1 to 350:1.

"DICOM images need ratios greater than 500:1," Primo added. Brightness and high contrast are stabilized at a consistently high level for the entire service life of the Siemens equipment and are included on each device during production. Siemens has also developed its Dual Domain IPS technology, which guarantees consistent grayscale display and luminence over a very wide viewing angle.

Image lag and open architecture are other key factors to consider, according to Hansen. In August, NDS introduced the EndoVue surgical display, which features NDS’ Image Lag Reduction (ILR) and Picture Perfect Technology (PPT). ILR greatly improves the display’s response time and reduces image lag, while PPT eliminates jagged edges that appear when interlaced video signals are displayed on an LCD. "ILR technology anticipates the LCD drive level. The end result is a super fast response time where image lag is negligible," said Hanson.

In September 2004, NDS launched its AXIS (Accurate X-Ray Imaging System) Series display, which provides open architecture, lifetime DICOM calibration and a 12-bit grayscale palette. Its "intelligent" controller allows for interfacing with any standard DVI video card (that uses a linear LUT).

"We know display independence is what prevails," Hansen noted. "Aside from accurate image quality, we want our displays to be self-contained and as compatible as possible."

From PCs to TVs
Facilities in the market for "all-in-one" LCD PCs, which combine a flat panel display with a high-speed processor, integrated speakers, keyboard and mouse, among other features, may be pleased to learn that price is no longer the obstacle that it was in the recent past.

According to Mike Zabaneh, vice president of marketing for Tangent Inc., Burlingame, CA, it’s now possible to get an all-in-one LCD PC – with additional bells and whistles – at a modest premium.

"The problem, historically, with all-in-one LCD PCs has been the price. [Consumers] used to pay a $600 to $700 premium for these products, but they now only pay a $200 to $250 premium, on average," Zabaneh noted. In September, Tangent debuted its VITA All-in-One Flat Panel Touch Screen LCD PC for the healthcare industry. VITA integrates a 17-inch flat panel LCD touch screen into a slim and rugged aluminum enclosure.

"Touch screens are being widely adopted as the standard display in healthcare because they are more convenient, interactive, and provide more user-friendly access and communication between healthcare professionals and patients," he noted.

VITA comes with a cordless keyboard and mouse, built-in speakers and WIFI LAN capabilities. It also operates on low power — approximately 260W versus 450-500W for PC and CRT combos.

And don’t forget the value of LCDs for patient use, either. More than ever, hospitals are ditching the bulky CRTs in patient rooms and installing LCDs that can either be flat-mounted to a wall or brought right to the patient’s bedside.

"Facilities are wanting to enhance their image and are looking for products that are more streamlined, cutting-edge and aesthetically pleasing," said Glenn Rocco, national sales and marketing manager for PDi Communications, Dayton, OH. PDi offers a range of flat screen systems that not only offer a wide viewing angle, high brightness and resolution, but are also both television and computer monitor capable – which enables facilities to also use the systems for patient education.

The latest systems also include "cloned programmable" and lock-down features, as well as start channel settings and maximum volume controls. The goal, it seems, is to create a patient care environment that reflects that found in the high-end hospitality industry.