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Signify Premium Insight: Signify Premium Insights’ 2021 Predictions – The Results

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At the very start of this year, Signify Research’s analysts assembled to pick the key threads out of the turbulence of 2020 and use them to discern the forces that would shape medical imaging in 2021. Here we revisit the predictions made about the Imaging IT, AI and Modality markets, and assess how clear the crystal ball really was.

Imaging IT and AI Markets

There will be limited releases of advanced clinical and diagnostic tools in 2021

Score: 8/10

This prediction was, with a few exceptions, very accurate. Throughout the year there were only very limited releases of imaging IT solutions that were truly new. Instead, 2021 was for most vendors a year of introspection and refinement. Several hugely impactful technological shifts are on the near horizon, with meaningful AI, cloud adoption and true enterprise-wide imaging IT, but Imaging IT vendors must first prepare their systems for such tectonic changes. While these longer-term goals were being developed in the background, the releases that saw the light of day in 2021 were those focused around workflow and operational efficiency.

There were a handful of high-profile releases, with GE Healthcare’s TruePacs, IBM Watson Health’s AI and Workflow Orchestrator platforms, Change Healthcare’s Stratus Imaging and Nuance’s Precision Imaging Network the standouts. However, in keeping with vendor’s priorities of preparing for the future, several vendors instead shared strategic plans for significant platform releases, and laid out their roadmaps towards these longer-term goals. As such most releases added additional functionality to existing systems or represented vendors catching up with their peers.

Overall, 2021 was, in essence, predominately a year of stage setting, ahead of the real show in the coming years

RSNA 2021 will herald the recovery of clinical and diagnostic innovation

Score: 6/10

This prediction painted an optimistic picture in which Covid-19’s role at the centre of medical imaging and healthcare in general would fade throughout the year. Vendors and providers alike would therefore be able to increasingly devote their resources to technological innovation, vendors would arrive at RSNA 2021 bristling with innovative leaps and providers, who had been holding off making purchases until they saw these new products, would arrive in Chicago ready to buy.

The reality was somewhat different. RSNA 2021 was smaller than previous years’ meetings with both fewer attendees and fewer exhibitors. There were some innovative new solutions on display, but, as predicted many of these had already been given soft launches earlier in the year, with the likes of Sirona Medical, Paxera Health and Change Healthcare all demonstrating products that had broken away from the traditional show-based release cycle.

At RSNA 2021, surprises, one of the clearest indicators of innovation, were few and far between. However, the foundations of innovative new products were being built, with quiet conversations taking place amongst vendors, heralding the formation of partnerships, between vendors and providers as AI developers and others look to forge ahead with pilot and clinical validation studies. The buds of innovation were quietly growing, even if the blossom was not yet on display.

Structured reporting will gain further traction in 2021

Score: 10/10

This is exactly what happened throughout 2021. While structured reporting isn’t yet universal or essential, the number of developments made in this direction are hard to ignore. From Agfa Healthcare’s release of its Precision Reporting tool, Smart Reporting’s marquee agreements with GE and Siemens to Blackford Analysis’ integration into the 3M Modal Fluency Direct reporting tool. This latter example is particularly significant as the integration of AI into a reporting solution not only exemplifies the strides structured reporting has made this year, but also places the two highly complimentary technologies together, allowing each to bolster the other and therefore help drive the adoption of both.

Structured reporting will only become more important. As AI becomes ever more significant, diagnostic data will become key, and this is what structured reporting unlocks.

This progress doesn’t mean there is no more work to be done, structured reporting isn’t yet the competitive differentiator it is set to become, and it isn’t yet a mainstay of dedicated premium offerings, as it will be. Perfecting structured reporting is difficult, doubly so when considering its clinical integration and deployment, but the corner feels like it has been turned and momentum is building. This is true both of the releases that have been made over the year, as well as the subtler anecdotal examples, with many vendors who have not yet made announcements working hard away from the limelight to bring the technology to bear.

As predicted, for many 2021 will have been the year that saw structured reporting move from longer-term strategy to current objective.

There will be consolidation in the AI market

Score: 2/10

This prediction fundamentally rested on the assumption that the medical imaging AI market, which at present is worth only several hundred million dollars, was too small to support the hundreds of developers trying to capitalise on the space. This assumption was true in and of itself but underestimated the continued appetite among VC investors to artificially support the market until revenues increased. This was particularly true in some parts of the world, with investors in several countries including China and South Korea keen to continue investing in their country’s young AI outfits.

Many vendors did recognise that success would be difficult to achieve alone, and that they would struggle against more established and better funded competitors, but instead of becoming acquisition targets, some of these vendors forged partnerships with other AI vendors, or indeed became targets for partnerships, allowing multiple vendors to combine their capabilities in a bid to create a more attractive package for providers.

It could be inferred that some vendors did have to make difficult financial decisions. One of the only major examples of consolidation saw Zebra Medical Vision bought by the challenger modality vendor Nanox. As highlighted at the time, Zebra had not secured any VC funding in several years and an acquisition from Nanox, a vendor rich in cash after its 2020 IPO, could have represented something of a lifeline for the Israeli developer. Aside from this, however, M&A activity was limited.

This consolidation is expected in the future, but amid the continuing Covid-19 volatility, healthcare represents a relatively safe haven for investment. Whilst ever this investment is forthcoming, the majority of this consolidation can be staved off.

The Imaging IT market appears relatively robust in the face of Covid-19

Score: 8/10

The difficulties faced by many medical imaging IT vendors throughout 2020’s covid related disruption meant that when this prediction was made the future was very uncertain. The cancellation of countless lucrative elective procedures as well as the swift reprioritisation of budgets at providers meant that for a spell, the outlook for 2021 looked bleak.

As highlighted in the original prediction, Imaging IT’s recurring service-based revenues and the additional Covid funding was expected to be enough to support the market throughout 2021.

However, while all these elements rang true, the prediction was too conservative, and, as illustrated in the chart below, the overall market is forecast to perform more strongly than originally anticipated; largely bolstered by the recovery of mature imaging IT markets. Upsell of home reporting, universal viewing, workflow tools and professional services further also buoyed the market.

The above compares annual growth for the global imaging IT market (inclusive of radiology IT, cardiology IT and advanced visualisation IT). Data points are from: Signify’s original 2020-2024 forecast (pre-covid); the COVID scenario analysis conducted in January 2021 which provided interim guidance on perceived best case / worst case scenarios for the imaging IT market; from the latest Imaging IT Core Report, published August 2021, we’ve included the 2020 actual market numbers and 2021-2024 forecast.


Modality Markets

Expanded access to medical imaging

Score: 9/10

This prediction proved to be one of the major trends in medical imaging modalities throughout the year, with many different vendors across different modalities being represented. In ultrasound, and particularly handheld ultrasound where this path has been trod for the last few years there was a major new product release from GE, as well as progress from a growing cohort of challenger vendors. Butterfly Network, which leads this pack, completed its IPO deal earlier in the year, while a number of other handheld players, including, Clarius, Vave, Exo, EchoNous, Pulsenmore, and more were all represented.

This trend was far broader than handheld ultrasound, however. MRI and CT saw progress from the likes of Siemens Healthineers and Philips which both launched MRI systems that enable the modality to be adopted in new clinical settings, through developments such as lower cost, lighter systems, easier to install, and the lack of requirement for helium refills. There were several new mobile X-ray systems launched or teased, including those from GE and Konica Minolta, reinforcing the growth opportunity of this product segment not only in developed countries, but to provide access to imaging in emerging countries. In addition, younger, challenger vendors such as Hyperfine, Turner Imaging and Nanox, also made headlines, although their progress in the market is harder to ascertain.

More broadly, outpatient sites are also playing a larger role in medical imaging, this transition is further expanding access to medical imaging, with many patients now able to access many scan types closer to their homes and places of business than in the past.

AI-enabled imaging acquisition

Score: 9/10

This is another prediction that resolutely came to fruition in 2021. The clearest illustration of this trend was at RSNA, which saw AI image acquisition and quality control solutions form a key part of many of the hardware launches and demonstrations at the conference. These were on both the workflow side with AI-powered automatic positioning and auto-protocolling systems that help improve the efficiency of imaging departments and minimise the need for rescans. There was also a prevalence of AI-enabled image acquisition and enhancement offerings, with AI tools significantly reducing the time it takes to conduct scans, effectively making these modalities more efficient and less resource intensive to use, and therefore enabling them to increasingly be used in non-traditional settings, as per the above prediction. Ultimately, these tools have quickly gone from being an innovative new feature to an essential tool, with any vendor neglecting them looking increasingly outgunned. Within the X-ray market, AI enabled camera-based workflows are also driving this initiative.

There were also other illustrations of this prediction. In the summer Butterfly Network and Caption Health partnered to enable the latter’s AI-guidance tool to be used on the former’s handheld ultrasound devices.

The original prediction did suggest that AI developers offering acquisition and enhancement solutions could be acquisition targets for large modality vendors. While this hasn’t come to pass, all other aspects of the prediction did.

Extracting value will be key

Score: 6/10

The importance of value was clear in 2021. In acknowledgment of the tighter financial circumstances that many providers found themselves in as a result of Covid 19, vendors were keen to promote their more affordable performance systems and help solve providers everyday challenges. In addition to promoting these systems, vendors also worked to expand the feature sets of these lower-tiered systems, while also in some cases moving to smart contracts which enable older systems to be regularly updated with the latest features, keeping them current and allowing providers to gain maximum utility of the systems. Within the MRI market, GE Healthcare’s ARTIS EVO enables bore size to be upgraded without the need for reinstallation, increasing longevity of the system.

This also went hand in hand with the increased focus on workflow efficiency throughout the year, as providers were often forced to attend to more patients with fewer resources.

This shift hasn’t been as dramatic as expected, however. Covid relief funding has continued to support providers’ purchasing of higher-end systems. In fact, for some modalities such as ultrasound, it has actually been the higher-end products driving growth in some regions. This has also enabled providers to continue to purchase from vendors they have had long-time relationships with, and therefore not given the opening to cheaper Asian vendors as originally expected.

Value was and will always be important to providers, but their spending has been more robust than originally predicted.

Shared service systems will increase in uptake

Score: 8/10

This prediction was mostly accurate. While there were no single key moments highlighting the development of this trend, a number of releases throughout the year indicated its steady growth.

In ultrasound, where the trend has perhaps been building the longest, several new products were released, including Samsung’s new V8 ultrasound and Esaote’s new MyLab X75 ultrasound, which can both be used as shared service systems. Shared service was also developing in other modalities. Siemens Healthineers announced its first install of its Luminos Lotus Max Fluoroscopy/Radiography system, while Fujifilm’s newly revealed mobile C-arm also offers DR functionality.

The growing prevalence of these shared service systems is, in many cases hindering the uptake of dedicated systems, even if on paper they can claim some advantages. As vendors and providers are increasingly entering into broader purchasing arrangements, and purchasing decisions are being made higher up within a provider, these shared service machines can represent better value, and therefore look to be an increasingly attractive option.

AR will gain traction in surgical rooms

Score: 2/10

While augmented reality remains an interesting technology which harbours significant potential for surgical rooms, for the most part, it hasn’t moved on since this prediction was made a year ago. This is understandable. As hospitals have reopened after the worst of the coronavirus restrictions in 2020 and early 2021, they have had to deal with an unprecedented backlog of postponed elective procedures. This influx of patients has absorbed the attention of providers and left little resource or desire to experiment with incorporating advanced technologies which may not bring tangible benefits immediately.

Although progress has been minimal over 2021, there have been some developments that do suggest interest in the technology will continue to grow over time. Most recently, Philips expanded its ClarifEye augmented reality surgical navigation solution to two new international sites, in Oman and Spain, with successful clinical outcomes.

AR will come to surgical rooms, but that tipping point didn’t come in 2021.

About Signify Premium Insights

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify ResearchTo view other recent Premium Insights that are part of the service please click here

Revenue growth for fixed General Radiography and Fluoroscopy is set to reach 10% and 8% respectively in 2021

The fixed digital radiography market is expected to grow at 10% year-on-year in 2021, reaching $1.1 billion, whilst the fluoroscopy market will also experience good levels of growth at 8%, closing 2021 at $463.2 million. These figures, taken from Signify Research’s General Radiography & Fluoroscopy – World 2021 report, show an encouraging rebound after a challenging 2020, during the COVID-19 pandemic.

Demand to switch from mobile to fixed radiography in 2021

The general radiography market grew by 12% in 2020, due to the exceptional demand for mobile radiography systems. The world market for mobile radiography systems is estimated to have increased by an impressive 77% year-on-year.

Mobile digital radiography (DR) systems are at the forefront in providing initial screening for pneumonia, a secondary and more progressive stage of COVID-19 in severe cases. Mobile DR systems are also used to track progression of pneumonia due to the capabilities of bedside imaging, enabling their use in emergency rooms, A&E facilities and in the ICU. During the peaks of the pandemic, hospitals and healthcare facilities around the world were desperately attempting to procure mobile radiography systems to supplement existing inventory in the face of supply shortages at most of the leading vendors.

As healthcare facilities rapidly sought out mobile systems, often discarding brand loyalty for whatever systems were available, budgets were diverted away from fixed radiography systems and fluoroscopy systems. The fixed digital radiography (DR) market declined by 14% year-on-year in 2020. In unit terms, 11% fewer fixed DR systems were sold in 2020. As the pandemic begins to subside, and healthcare budgets gradually return, investment in the fixed general radiography market is projected to return to pre-pandemic levels by the end of 2021.

On the contrary, the global market for mobile radiography systems is projected to see a sharp decline of 39% in 2021. With most hospitals and health clinics having recently purchased mobile radiography systems during the pandemic, the inflated installed base will restrict the need for new systems in the coming years. The market is forecast to return to growth in 2023, driven by the replacement of older analogue systems.

Stronger growth forecast in multi-purpose fluoroscopy

The fluoroscopy market experienced a challenging year in 2020. With fluoroscopy budgets diverted to COVID-19 response, alongside fewer fluoroscopy procedures, the market saw a 19% decline in revenue. Clinical demand is shifting away from fluoroscopy to CT and endoscopy, further threatening this market. The main procedures that remain a stronghold for fluoroscopy include barium-swallow scans and upper GI procedures. Stronger growth is forecast for multi-purpose systems which can perform both radiography and fluoroscopy, due to wider clinical usage and associated higher return on investment. After the steep decline in 2020, the fluoroscopy market is expected to gradually recover and surpass 2019 revenue levels by 2024.

Key trends by region

North America

  • Unlike most other world regions, North America and in particular the United States, remains a classical fluoroscopy market, with far lower uptake of remote imaging, due to the associated detachment from the patient and concerns of jeopardising image quality and subsequent litigation.
  • Brand loyalty continues to be strong for general radiography equipment, to prevent retraining and adjustment of workflows.

Latin America

  • Demand for analogue and CR systems remains high in Latin America, with the lower prices being a key deciding factor. In Brazil it is estimated that 85% of general radiography exams are still conducted on analogue systems, a far higher number than many other emerging countries. However, with falling prices of flat panel detectors, digitalisation is expected to gather pace in the coming years.
  • Fluoroscopy remains a small market in Latin America due to the relatively high system prices yet lower utilisation due to the niche clinical applications they address. The shortage of trained radiographers is also holding back the fluoroscopy market.

Western Europe

  • The general radiography market in Western Europe continues to remain focused in the higher end market segment, especially floor-mounted systems.
  • Fluoroscopy continues to be a very small market in most Western European countries, with France being the exception, where the market for remote systems is forecast to increase over the coming years. France is unique in that hospitals use fluoroscopy for patient positioning and to localize where to start imaging, and this modality is therefore used frequently. Additionally, there is a strong replacement market and older systems are typically replaced like-for-like and not with a multi-purpose system. Most other Western European countries have much less uptake of dedicated fluoroscopy equipment.

Eastern Europe, Middle East and Africa

  • Lower-cost analogue solutions continue to sell well in the African general radiography market. In Eastern Europe there remains a focus on floor-mounted digital X-ray solutions, as the lower price point is a key factor in this price-sensitive market.
  • French speaking parts of North Africa still have a strong demand for fluoroscopy systems, following France in this trend. Elsewhere, demand remains lower.

Asia Pacific

  • The fluoroscopy market is largest in China and Japan, with all other Asian countries having very limited uptake, as other modalities are favoured for traditional fluoroscopy procedures.
  • Lower cost floor-mounted systems continue to dominate the general radiography market, especially in China.

Competitive analysis

In 2020, Carestream consolidated its position as mobile DR market leader, followed by GE Healthcare, Siemens Healthineers, Philips and Fujifilm.

Siemens Healthineers and GE Healthcare secured the position of joint market leaders in the fixed DR market, with GE Healthcare gaining significant share in 2020.

Siemens Healthineers was the world market leader for fluoroscopy in 2020, with Shimadzu, Canon Medical and Philips following.

Future outlook

The fixed DR market will rebound in 2021, as budgets and investment will return to fixed radiography rooms. Signify Research forecasts investment will gradually return for high-end DR solutions, such as ceiling suspended and multi detector systems from 2021 onwards. Growth in the low-end fixed DR market is forecast to primarily come from emerging regions, such as Africa, Latin America and Asia, where there is a significant installed base of analogue radiography and computed radiography ready for digitalisation. Growth in the fluoroscopy market will be limited as clinical procedures move from fluoroscopy to CT or endoscopy. As a result of increased focus on cost-efficient solutions and return on investment, most of the demand for fluoroscopy equipment will be captured by multi-purpose systems capable of performing general radiography procedures.

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