The dark side of modern X-ray equipment

Veterinarians find digital radiography expensive, maddening

June 8, 2017 (published)
By Edie Lau

ClearVet unit in use
Photo courtesy of Blue Spruce Animal Clinic
Veterinary technicians Amanda Mehring and Megan McMahon position a patient on a ClearVet digital radiography unit at Blue Spruce Animal Clinic. Clinic owner Dr. Albert Chai was frustrated repeatedly by the machine’s performance and vendor support. “We built this practice from zero clients, and everything is very modern, so I do consider myself conversant in digital devices and machinery,” Chai said.

The $55,000 X-ray machine that Dr. Albert Chai bought for his veterinary practice in Castle Rock, Colorado, began acting up almost immediately.

First, the computer on the ClearVet DR9 MPX digital radiography machine wouldn't communicate properly with the practice-management software. Attempts by the manufacturer to fix that problem seemed to cause new ones: Images came out lacking in detail, or the system outright crashed, requiring a time-consuming restart.

"[W]e decided to stop contacting them to fix these small issues because it seemed to only make things worse," Chai told the VIN News Service in an email narrative of his travails. But the issues became more serious and frequent before the machine was three years old. "We were consistently shooting only one film before we had a gray blob appear on our X-ray image," he said.

The clinic contacted the manufacturer, ClearVet Digital Radiography Inc., which happens to be located 15 miles away in Centennial, Colorado. Sometimes, a technician immediately examined the system remotely, by computer; other times, the clinic waited a day or longer for a response.

Chai reported: "During this time, they would remote in multiple times to make changes to software/calibration. None of this helped. This continued for a couple weeks (during this time, X-rays were touch-and-go). Finally, the machine stopped taking films altogether."

This was last spring. The machine was under warranty still, but Chai found the servicing unreliable. While waiting weeks for repairs, the clinic disappointed clients and lost business. "We were even unable to help a dog that swallowed a foreign body because we could not diagnose it," Chai said. "They ended up going somewhere else for X-rays and subsequent surgery."

Chai learned that ClearVet had only one technician, with a second in training. When the company sent a third-party technician who found a bad sensor, Chai discovered that the five-year "total system warranty" did not cover labor after one year. "Even though it was a faulty part, we still had to pay for the travel time and labor to replace it," he said.

And the ordeal wasn't over. Replacing the sensor worked only temporarily. In late October, the gray blobs reappeared. More sluggish and ineffectual servicing followed.

In mid-December, following a conversation with the VIN News Service about customer complaints, ClearVet traced Chai's troubles to a bad detector. ClearVet replaced the $10,000 part. That was the resolution the clinic had waited nearly three years for. Today, Chai reports, "The machine is (knock on wood) still working."

Other ClearVet customers relate similar frustrations and less satisfactory outcomes. One practitioner was given $2,500 in a buyback of five-year-old equipment for which she paid $55,000 new. Another continues to struggle with a two-year-old machine that began glitching after nine months. A third reports being shamed and blamed for poor housekeeping.

ClearVet executives told the VIN News Service that the company has a good record of reliability and service, and works diligently to address instances of persistent problems, which they maintain occur only rarely.

"These are very complicated and sophisticated pieces of equipment," said David Miller, vice president of business development. "There's a huge amount of operator error. I'm not saying these [particular] complaints, that these are operator error, but I've seen vets insist they know what they're doing, but [the problem] is operator error. Training and repetitive use fix those [problems]."

How much of the veterinarians' equipment troubles are attributable to the complicated nature of the machinery and how much stems from issues unique to ClearVet is hard to determine definitively, but there's no doubt that today's X-ray units are very different from X-ray units of the past. Like telephones, televisions and cameras, they've gone digital.

Different name, same leaders

Digital radiography (DR) units offer a variety of benefits, most notably, almost instant image-processing — there's no need to wait for film to develop. But the machines are more complex and sensitive, cost more upfront and are significantly less durable.

Life spans of five to 10 years

Dr. John Daugherty, a veterinarian for more than 30 years and a practice owner in Ohio, serves as an associate editor in diagnostic imaging and radiology at the Veterinary Information Network, an online community for the profession. Daugherty estimates that the useful life of a digital system is seven to 10 years — far shorter than the 20- to 30-year life of old-fashioned film-based X-ray units. The Biomedical Engineering Advisory Group of South Australia, comprised of biomedical engineering managers from hospitals in that state's public health system, gave a similar estimate — seven years — in a guidance paper, Life Span of Biomedical Devices, issued in 2004.

Noting that the image-capture end of modern radiography is "all computers and software," Daugherty said, "Computers will die or become obsolete … and then the expense [of purchasing a system] is incurred all over again. The vendors tend not to emphasize this aspect of their systems, and instead highlight the savings in maintenance costs compared [with] analog."

As in photography, the change from analog to digital radiography represented a massive technological shift. The X-ray generator itself is unchanged, but how X-ray energy is captured and converted into pictures is dramatically different, as Daugherty describes:

"In the very old days of film, we needed a darkroom [and] three chemical tanks — one for developer, one for fixer, one for rinse water — and this required plumbing, changing [and] mixing of chemicals, temperature control of the liquids in the tanks … lots of maintenance."

In time, most practices moved to automatic processors. "Still needed a darkroom and chemicals, but the films were fed into a machine that did all the work of exposing to the various chemicals, drying the films and presenting them to be read. This automation sped the process of developing an image from five minutes per film to around 90 seconds per film. It was a huge advance, but the machine still needed periodic maintenance, and chemicals had to be disposed of properly."

Enter digital technology. "The image capture is electronic, not chemical. Therefore, no darkroom, no plumbing, no chemicals, no maintenance. It also improved speed in the case of DR systems — a few seconds to get the image, rather than minutes."

All great, but for one thing: "As with all computer systems, operating systems become obsolete or unsupported. Computers run out of storage space and need to be upgraded, and software is constantly being improved. Therefore, there is still ‘maintenance' required, but it's not something that we can do ourselves."

In this way, practices are at the mercy of the vendors. That brings us back to ClearVet.

ClearVet is one of numerous manufacturers of veterinary digital radiography systems. Based near Denver, ClearVet is among several brands affiliated with Apexx Equipment, which, according to its website, repairs and sells used and new veterinary equipment. Apexx brands include Edan, ImageWorks Veterinary, Engler Engineering Corporation and Leading Edge Veterinary Equipment.

Drew Blackstone, a medical-equipment sales executive whose career began on the human-medicine side at Abbott Laboratories Diagnostics Division, founded Apexx in 2001, according to the Apexx website. Blackstone established ClearVet in 2008 and serves as its CEO. He did not respond to invitations conveyed by his staff to talk with the VIN News Service.

ClearVet emphasizes a goal of excellent customer service. As stated on its website, the company principles are:

  • total system accountability
  • provide complete warranties
  • on-time support
  • no excuses, no finger-pointing
  • create customers for a lifetime

Driving an adult to tears

Dr. Kim Buck might argue that the company could improve on its adherence to "no finger-pointing." Buck bought an emergency veterinary hospital in San Antonio, Texas, in 2014 that came with a five-year-old ClearVet digital radiography unit.

When problems arose with the machine in 2015, the warranty had expired. Buck asked about buying an extended warranty. She said ClearVet responded that because the warranty had lapsed, extending it would require an inspection. A technician visited and took photographs.

Later, while visiting her children at college in Utah, Buck received a call on her mobile phone. It was ClearVet. Buck recalls the agent telling her harshly that photographs from the inspection showed an unkempt, poorly-maintained space.

"They just really ripped through me by saying that the X-ray room looked horrible. We need new floors," she acknowledged. "The floors are, like, 16 years old. They're clean, but they look bad and there was hair around; hair and dust, basically. And I guess behind the machine, you know how you have a refrigerator and you don't go behind the refrigerator? No one had bothered to go behind the machine and clean, which we do now."

While Buck recognized that the space wasn't spotless, she said the ClearVet representative was so demeaning that she lost her composure and cried.

The type and frequency of problems Buck experienced with the radiography unit also were enough to drive an adult to tears. One problem related to the collimator light, which enables the user to direct the X-ray beam. "If we took too many X-rays, [the light] would heat up ... so much that it melted some of the wires," Buck said. ClearVet replaced the light box but used the same type of bulb, "so we started having the same problem again."

Buck turned to the internet to obtain a lower-wattage bulb and replaced it herself. "I did not want a fire," she said.

Buck has no complaints about the X-ray unit itself; she finds it produces good-quality images. "If they would just support it, it would be fine," she said.

Owing to her bad experience with customer service, Buck decided after paying for one year's extended warranty not to extend it further. She found an independent company that provides after-hours support — an important feature to someone running an emergency hospital. When she called them at 11 p.m. recently, a live person answered immediately.

Informed by the VIN News Service of Buck's experience, ClearVet's Callinicos said she would look into the case and declared that the humiliating telephone conversation Buck described "is absolutely unacceptable."

Her colleague Miller echoed that. "You cannot mistreat your customers," he said. "They're your lifeblood."

Ask a colleague

Regrets tolerating early glitches

Dr. Michelle Huddle set out in 2011 to equip her new solo rural practice in Valentine, Nebraska, with a digital X-ray machine. Huddle chose the ClearVet DR9 Megapixel in part because it came with a five-year warranty, which she found to be the longest available on the market at the time.

During the first five years, the machine operated fairly well — or so Huddle thought. Occasionally, it would warn "generator canceled," which required shutting down the machine, restarting and retaking the image. Huddle took the hitches in stride, not wanting to stress out about them. "I just need to move onto this next patient," she would think.

She did call the company several times to report the issue. Each time, she said, she was told that the problem was user error. In retrospect, Huddle wishes she'd been less accepting. "I should have pushed harder for answers," she told the VIN News Service.

The unit's performance worsened over time. "It basically took longer and longer to generate an image. They troubleshooted it a million different times," Huddle said. The answer always was: user error.

In February 2016, a month or so after the warranty expired, the machine stopped working. "We'd hit the button to take an image, and nothing would come up," Huddle recounted. Now a service call came with a steep fee: $1,600 for a technician to make the six-hour drive from metropolitan Denver to Huddle's clinic. Huddle also was offered an extended warranty for $400 to $900 per month, depending on the level of coverage.

Rather than pay for the on-site visit, Huddle opted for remote diagnosis. After several remote sessions, the problem was identified as a failing CCD detector. A CCD, or charge coupled device, is an electronic element integral to the process of forming the image. It's an older technology, and Huddle was told that the company no longer made the part. She was presented with the options of upgrading to a comparable machine for $35,000, retrofitting to a less sophisticated system for $25,000, or selling the malfunctioning unit back to the ClearVet for $2,500.

Huddle explored other avenues, hiring separate companies to evaluate her unit for repair or retrofitting. Nothing panned out. To get out from under, she accepted ClearVet's buyback. "I decided I wanted to cut my losses and just get rid of them," she said. "And that's what I did, and lost a ton of money."

So big was the hit, Huddle said, that she would have had to close the clinic or forgo offering radiographic services — which would have cost the clinic its American Animal Hospital Association accreditation — had she not had equipment-breakdown insurance. The insurance covered 75 percent of the price of a new machine, which she bought from a different vendor.

From ClearVet's perspective, this is what happened:

"After repair estimates were sent to Dr. Huddle and an offer made to her to upgrade her equipment that included deep discounts, she decided to sell her equipment back to us. We are the only company in the industry that will purchase our equipment back. So ... we sent a tech onsite, de-installed her equipment and gave her a check."

Frustrated from the beginning

Dr. Kasey Canton, a practice owner in St. Croix, Virgin Islands, started having reservations about his ClearVet DR9 unit almost immediately after he purchased it for $60,000 in 2014. For starters, the machine was represented by a salesperson as made in the United States, but the unit came in boxes labeled from South Korea.

Then he found that the company had installed the unit incorrectly, so that the table — the part the patient lies upon — would float in all directions when the user was attempting to take an X-ray. He said the installer told his staff that was by design. But that didn't entirely make sense. Floating is helpful when positioning the patient but not during the X-ray exposure. Inspecting the table, Canton saw that it had locking magnets that were misaligned. He recruited a family member to help him remove the tabletop and reinstall it properly.

In an email to ClearVet in November outlining his disappointments, Canton wrote: "About nine months after the installation, we started getting errors and having to restart the machine frequently. Tech support had to log in to reset things, and finally after a few months of this, the machine went inop. Your tech made two trips to my office to repair. We are currently getting the same errors that we were getting before that last repair. Our equipment has been in service only two years."

In mid-December, ClearVet's Callinicos told the VIN News Service: "We identified the issues Dr. Canton was having with his equipment, and despite his labor warranty having expired, we have not charged him for three visits to the island to complete the fixes." She reported that his unit was "up and running without issues."

In mid-March, Canton told the VIN News Service that the machine was acting up again, with "occasional blank screens and refusing to shoot." In mid-April, he reported, "[T]hey are now blaming power issues on our end for the poor performance of the system, and have offered no solutions whatsoever." A few days later, Canton said ClearVet worked on the system remotely for three hours and "somehow got it working…"

Canton remains uneasy. At Western Veterinary Conference in Las Vegas in March, he said, he spoke with several digital radiography vendors who were aware of problems at ClearVet and relayed that the company had "bought back a number of the DR9s." Canton said ClearVet itself was "conspicuously absent" from the conference, which he read as a sign that the company is on shaky ground.

"I have a bad feeling that I'm going to be left with a worthless machine when they close up shop," he said.

ClearVet's Callinicos said the company is not going out of business. "That's not the case at all," she said in late May. As for Canton's case, she acknowledged that his unit has "intermittent issues, and we're trying to work on figuring out what's the best course of action."

'We are on top of it'

When the VIN News Service first contacted ClearVet in November about problems reported by veterinarians, Callinicos responded quickly. In three lengthy telephone calls and by email during the next six months, Callinicos and Miller emphasized a desire to serve their customers conscientiously.

"Our goal is full customer service and customer satisfaction," Miller said.

Callinicos described the ClearVet team as including two technical-support staff; one customer-service representative; and two installers who also provide on-site repairs and some in-house technical support. She said the majority of technical-support calls are handled by one employee.

Asked if she should hire more help, Callinicos said, "I have no need to bump up my staff because we are on top of it."

She also said, "[W]e just don't get that many calls, to be honest with you. We do not have a lot of overall problems."

Callinicos said veterinarians often perceive the process of troubleshooting as taking an inordinately long time, not understanding that diagnosing the problem in the complex system may not be possible instantly.

"These particular machines … have three components," she explained: "You have the generator, then you have the actual X-ray component, then you have a PC. All three of them talk to each other. So sometimes, it takes more than five minutes to figure out exactly what's going on. … I feel like we get a lot of veterinarians that will call and they want it fixed right now."

Asked how many ClearVet units are in operation, Callinicos said the number is in the several hundreds; the exact figure is confidential. Of the proportion giving trouble on any given day, Callinicos said in late November, by way of example, "[T]oday, we have seven that we're working on, and five of those will be closed tomorrow. So we'll have two active."

She said the time to resolution for each case varies widely. Some can be remedied in 10 minutes. Others may take a few days, and some require an on-site visit.

Whatever the case, Callinicos said, "It is our goal to provide the best customer service that we can. We constantly take steps to make sure we're keeping up with our clientele and keeping up with practices as far as customer service goes, and looking to make sure we get better and better and better — not because we're not good enough now, but because you can always get better."

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