Tag Archives: Mustafa Hassan

Signify Premium Insight: Challenge Abounds, but Promise Remains for an Embattled Ultrasound Market

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Market Analyst
Mustafa Hassan

The Covid-19 pandemic, which brought unprecedented disruption to both the medical imaging markets and the broader healthcare sector in 2020, began to subside in 2021. However, there was no respite for beleaguered vendors and providers, which were instead beset by logistics challenges and supply chain headaches which abounded in the pandemic’s wake.

Such challenges are captured in Signify Research’s Ultrasound Equipment – World – 2022 report, with, according to the report’s author Mustafa Hassan, vendors primarily focused on managing and capitalising on the tumultuous effects such disruption is having.

“Amidst these supply chain challenges, vendors are finding ways to cope,” he explains. “Certain vendors may be forced to prioritise certain product lines or be forced to focus on certain modalities or particular products.

“These decisions will be based primarily on how vendors are able to manage their stock and secure their supply chains. The real winners from this period will be those vendors that are able to convert orders to sales and meet the customer demand.”

Although ultrasound systems are typically cheaper than many other imaging modalities, ultrasound business lines tend to be among the most profitable for vendors. As such, while vendors will be keen to continue to supply devices, and will be particularly keen to promote the upper end of their product ranges, which are typically the most profitable, vendors also have a slight cushion to be able to manage prices and absorb some increase if it allows them to continue to secure agreements with providers for products across the range.

However, such profitability also means that any shocks to ultrasound sales can have a significant impact to even those large multimodality imaging vendors with diverse portfolios.

Customers Footing the Bill

So far, however, such trials have been avoided.

“We saw stronger than expected growth in 2021,” Hassan notes, “but we do expect this growth to be somewhat stifled over this year and next year, because of the supply chain challenges and increasing costs, particularly for more premium products.

“As a result system prices have increased in nearly all regions. There are price-sensitive markets, such as Africa, where higher costs can’t simply be absorbed by customers, and some vendors will have to walk away from deals. However, for any vendors that can make a deal at those prices, such as some in China, for example, there could be some opportunity.

“More generally though, I don’t think there is a really exceptional opportunity for any vendor in particular, because everyone is fairly equally affected. Even where there are differences, with some Chinese vendors potentially being less affected by chip shortages, other factors come into play, such as the additional lockdowns in that country. The differentiator will be how effectively vendors are able to manage these challenges.”

There are several options; vendors will likely be reluctant to pull away from emerging markets, but because of the challenge of sustaining margins and increased volatility, however, they will prioritise products at the most profitable markets. For example, if releasing a new product into Europe, instead of a Europe-wide release, vendors will now focus the product release to specific, high-priority countries.

Efficient Purchasing

Fortunately for the vendors, their customers are receptive to new technologies and products that they are introducing.

“Given the backlog in procedures as a result of the Covid-19 pandemic, there is a growing trend in ultrasound, as in the wider medical imaging market, of efficiency being a priority. Vendors are really working to help improve the efficiency of sonographers and other clinicians, and help them avoid burnout and fatigue.

“This is helping to drive the adoption of new technologies which can help with burnout, such as AI , and is one of the reasons that vendors are able to keep selling new products. Teleultrasound platforms are also helping connect expert sonographers to less experienced users, improving efficiency and accuracy in reporting.”

This is one of the reasons that vendors are able to continue to be optimistic despite the current headwinds. Despite having to face stiff supply chain challenges, and reduced budget in some regions, due to large government funding offered in 2021 in the wake of the pandemic, the backlog stemming from the Covid pandemic continues to create the need for more systems, representing an opportunity for ultrasound vendors.

Given these considerable headwinds and the significant growth experienced in 2021, vendors may have feared a correction in 2022 and beyond, according to Hassan, however, this looks unlikely to materialise.

“Given last year’s growth, you would expect a market decline in 2022, but there hasn’t been. The rate of growth will slow, but it has continued. There is some regional variation. In the US, for example, there was significant growth in 2021, which has continued into the first half of 2022. It will likely slow in the second half, but the overall picture will be of growth. In other markets there was a decline. Russia is no surprise because of its conflict with Ukraine, but there was also a fall in other places such as Japan, due to the 2022 supplemental budget being significantly less than the budget in 2021.”

An Ultrasound Transition

Ultimately however, the outlook is generally positive for ultrasound vendors. One of the lasting legacies of the Covid pandemic is that providers are better appreciating the value of ultrasound as a diagnostic modality.

“Before the Covid pandemic, some providers saw ultrasound as the inferior sibling of other modalities such as MRI, CT and X-ray, but ultrasound’s use during the pandemic highlighted the capabilities of the modality, and its broader use within medical imaging. As such providers are looking at the modality more seriously than previously.”

Hassan continues: “Key to this is the fact that ultrasound exams are radiation-free, real-time, low cost and can be carried out efficiently. These benefits will continue to be valuable in the coming years, and will be able to come to the fore as other technologies improve.

“One of the biggest challenges with using ultrasound, for example, is having enough trained staff to be able to acquire and read an image. That has always been a big problem, but AI will increasingly overcome this barrier in the future. It is still in its infancy at the moment, but the wheels are in motion.

“This is particularly true for some use cases, particularly in conjunction with teleultrasound platforms allowing examinations to be done remotely. So, for example there is a growing appetite in cardiology for AI enhanced ultrasound, triage is another good use case, particularly with the growing use of handheld systems. Breast screening is another use case where ultrasound makes sense, even if mammography remains the gold standard, ultrasound could be a useful tool for younger women, or those at a lower risk of breast cancer.”

Clinical Sense

These technological innovations and new uses will help foster new growth beyond the already strong growth drivers in traditional imaging markets, with cardiology, radiology and women’s health all instances where ultrasound is particularly attractive.

“There are challenges at the moment,” Hassan concludes, “but vendors can be positive as these challenges will, at least, be affecting every vendor in the market fairly equally, and for all the disruption caused this year, are not expected to be multi-year issues. Instead, when vendors look at the mid-to-long term, the conditions are actually very favourable, with both significant clinical and technical drivers of growth. After the short-term disruption, the market is very promising.”

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Signify Premium Insight: “What Customers Want Are Solutions that Make Their Work Easier” – The Key Trends in Ultrasound AI

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 Research. To view other recent Premium Insights that are part of the service please click here.

Medical imaging AI is a young but rapidly developing market. Vendors have taken great strides in developing, testing and commercialising solutions which are, in many cases being implemented and adopted. These trends are detailed in Signify Research’s AI in Medical Imaging Service. However, while many of the currents of the medical imaging AI market are widely applicable, there are specifics that make the market for ultrasound AI unique.

Chief among these, explained Signify Research Market Analyst Mustafa Hassan, who authored the Ultrasound AI report, the first deliverable in Signify’s Ultrasound Market Intelligence Service – World – 2022¸ is the fact that ultrasound AI needs to be applied in real time when obtaining ultrasound images. “In many ways it’s more challenging to develop AI solutions for ultrasound, as solutions for image capture need to be applied as a user is obtaining the images, rather than being used for analysis after acquisition as is the case for most modalities. Such post-acquisition analysis solutions, in ultrasound as well as other modalities, can often be simpler to develop.

“This is particularly important given that, in some ways, ultrasound is the most technically difficult modality to master. Compared to X-ray or MRI, it can be a lot more challenging, both in terms of the technical skill required to acquire images, but also in terms of the time it can take to analyse images. If you don’t know how to position the probe correctly, you will just end up obtaining a bad image.”

Resolving Issues

AI vendors have different areas of focus in solving these problems, some of which are unique to ultrasound, while others are more general. Broadly, these four areas are image capture guidance, workflow optimisation, image analysis and decision support. Despite these broad applications of AI, however, the minutia of AI’s use is still less well defined.

“Vendors are having to answer a lot of questions at the moment,” highlights Hassan. “One question, for example, is how best to deploy AI. Do you deploy it on the device itself, on a workstation? Or do you do it all on the cloud?  Most ultrasound AI solutions are currently deployed on either the device or on a workstation, with very few cases of cloud-based deployments.

“Although cloud adoption is low for ultrasound AI today, the market is heading in that direction, but the adoption of cloud-based AI solutions will be nuanced and closely related to functionality and performance need. This is expected to take place over several years. In the short-term, most ultrasound AI deployments are expected to be on-premise, either on the device, workstation or virtual machine.

“Which option is best is very dependent on the solution. For instance, if it is an image guidance solution, then it can only be deployed on the device because it is needed to help obtain the images. Image analysis solutions, on the other hand are more varied, with the solutions being able to be used in various settings, giving flexibility to the customer. Performance, efficiency and processing will factor into how AI solutions are deployed.”

This question impacts other pivotal aspects of the market, with for example, it influencing the type of vendors that are actually investing in developing such solutions. In the earliest days of the market, many ultrasound OEMs focused on developing their own AI solutions in house, before deploying them on their own devices.

This early trend is now starting to shift, however, with OEM manufacturers increasingly partnering with specialist AI vendors. A combination of native AI development and selective partnerships provides agility for OEM manufacturers in the market and will save on development costs. One of the areas that these partnerships have been particularly keenly adopted in is the handheld segment.

The Matter at Hand

For independent ultrasound AI vendors, there is sense in partnering with OEMs in ultrasound’s fastest growing segment and looking to “democratise” ultrasound by making it easier to use by novice users however, this approach is also particular to the segment.

“Most commonly when an advanced technology or a new feature is released into the market, it is given to the highest priced systems, and then migrates down throughout the range over time. That’s also the case with ultrasound AI for workflow automation and image analysis, with solutions being first offered alongside the most expensive solutions.

“Often, however, in the case of ultrasound, the users of the most premium systems tend to be experts in ultrasound. They know what they’re doing, and in many cases, will derive less benefit from AI assistance, and will be less inclined to adopt it. “Where vendors will actually see people wanting to use AI is in smaller community hospitals and clinics. Places that, instead of premium systems, will be using lower-cost systems and where customers may lack expertise in ultrasound.

“There is also a need for AI solutions in low-income and remote/rural areas, where handheld systems will be a good fit. The devices are affordable enough for any user, but those are also the users that need support the most. This is especially true given the increasing adoption of handheld ultrasound outside of traditional imaging settings and among novice users.”

This of course isn’t an exact, clean division, and there are cases where users of premium systems would see value in AI solutions, but in many cases, it will be users of vendor’s lower-tiered products that will benefit the most from AI tools, a factor that could make deriving significant revenues from AI solutions a fine balance.

The Heart of the Matter

Given the possibility to benefit less experienced users, ultrasound AI is particularly suitable for some segments. Cardiac ultrasound is one such specialism. Aside from heart disease being one of the most sizable health burdens across the globe, cardiac ultrasound is also a discipline that lends itself to AI assistance given the challenges of image acquisition and the need for quantitative measurements.

While this is one of the more obvious clinical areas for ultrasound AI adoption, Hassan also expects certain other areas to grow particularly strongly.

Notes: 1. Market estimates only include sales from Independent Software Vendors (ISVs). 2. Sales of ultrasound AI products by ultrasound equipment OEMs are not included. 3. Market estimates include sales of the following software: 1) image capture, 2) workflow automation, 3) image analysis, 4) decision support

“Of course, cardiology is going to be a big one,” he opines, “but I think another area to look out for is women’s health ultrasound AI. There are not many AI vendors developing solutions for women’s health. We have seen the first solutions receive FDA approval, and this momentum will only grow.”

Thyroid ultrasound is another one to watch. “It is,” he explains “another area where AI assistance will be very useful given the difficulty of the scans, with some providers even losing money doing these scans due to the time it takes and the limited reimbursement. AI will have real benefit there. While it won’t drastically increase the use of ultrasound for thyroid imaging it is an area where I see AI having a big clinical impact.”

Other clinical areas also look ripe for AI adoption, with breast ultrasound another modality that could benefit from the technology. However, as with breast ultrasound more generally, adoption could be slower given the reluctance in some corners to switch to ultrasound from mammography.

International Purchase?

Different markets are also expected to adopt the technology at different rates. Given the increasing availability of reimbursement, the appetite among private providers compared to public health systems, and support from a number of influential opinion leaders, North America is unsurprisingly set to be the quickest growing market. In other markets, conditions for adoption are less fertile.

“On paper China looks like a good fit for the adoption of Ultrasound AI. It has a huge population, as a country it has embraced AI more generally, and it is looking to expand healthcare to rural areas,” notes Hassan. “However, ultrasound AI is being held back by stringent regulatory approval process.”

“There are developed solutions, but no AI vendor in China has yet received NMPA Class III certification, which would allow their AI solution to be used for diagnostic purposes. The only solutions that have yet been approved are NMPA Class II, which can only be used for productivity and workflow purposes.

“Some Chinese AI vendors are reportedly sidestepping the regulatory process by stripping back their products to secure Class II certification, and then selling them to customers on that basis. Vendors have been pushed to such strategies because of the costs and challenges in providing clinical validation in the country, holding the whole market back.

Paying for Problem Solvers

Notes: 1. Market estimates only include sales from Independent Software Vendors (ISVs). 2. Sales of ultrasound AI products by ultrasound equipment OEMs are not included. 3. Market estimates include sales of the following software: 1) image capture, 2) workflow automation, 3) image analysis, 4) decision support

There are limitations and barriers to adoption, but the same is true of any young technology. Significantly, there is no insurmountable obstacle to growth. Signify’s report analyses the revenues generated by independent software vendors and forecasts rapid growth, with a CAGR of almost 80% for the forecast period 2020 – 2025. Although starting from a low base of $3.4m, and the market, at little over $60m at the end of the forecast is still small compared to AI segments for other imaging modalities, this does represent an impressive increase for such a nascent technology.

Hassan points out, however, that this is still just the beginning. “It will grow more in the longer term,” he emphasises assuredly, “it will just take time to be adopted.”

This, he points out, is because ultrasound AI can solve some of the most fundamental problems with ultrasound.

“If you look at the challenges with ultrasound where it can be hard to capture an image, it can be hard to properly analyse images, it’s very complex and doing these examinations can be very time consuming. These are very real issues with ultrasound which can be addressed with AI.

“So, while there is a lot of hype and excitement surrounding AI in ultrasound, and it has, in some cases become just a buzzword, there are a lot of great opportunities for its use.

“Vendors just need to make sure they focus on developing solutions that really have an impact on customers’ work. Essentially, what customers want are solutions that make their work easier.”

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Signify Premium Insight: Trends and Takeaways from RSNA 2021 – Medical Imaging Modalities

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 Research. To view other recent Premium Insights that are part of the service please click here.

There have been some major announcements throughout the year that may have somewhat robbed RSNA of its thunder. From Philips launching its latest flagship spectral CT scanner in May, to Siemens revealing its photon-counting CT system, and a new whole-body, low-field MRI system over the past months. Other factors could also have put a dampener on the radiology conference. As has been widely reported attendance at the event was far lower than it was in previous years, while a few high-profile vendors also were unable to attend due to coronavirus restrictions in their countries and companies.

However, despite all this, the vendors, radiologists and providers in attendance were generally very positive about the conference. This was perhaps in part the result of meeting in person again for the first time in two years, but also no doubt down to the solutions being shown to providers.

Tools for a Job

One of the themes that united these different products from different vendors was their focus on straightforward, practical utility. Vendors did, of course, show off their latest feature-rich flagship systems, but they were also keen to promote the mid-tier ‘workhorses’ of their ranges. This is in large part due to the situation providers find themselves in. With large backlogs of patients, which had elective procedures and examinations postponed because of Covid restrictions, providers are looking for cost effective and efficient systems across the modalities, which will allow them to address this backlog most effectively. In most cases vendors were looking to meet this need with existent products, often with new features and software applications, rather than showing new products specifically catering for this product tier.

A corollary of this pattern saw vendors exhibiting products that had feature sets which enabled providers to attend to patients more efficiently and increase patient footfall. This was particularly true in MRI and CT, which have higher scan times, as opposed to X-ray and ultrasound. Imaging vendors were increasingly drawing attention to tools such as embedded cameras to enable technicians to more easily assess a patient’s position before the image is taken and ensure that the scanner will be able to capture the required image.

These hardware developments were also tied to software improvements, with technologies such as smart protocolling being demonstrated at the conference. These technologies offer numerous benefits. They will improve the broader departmental efficiency by improving the number of ‘right-first-time’ scans, and therefore saving radiology departments from having to conduct rescans and reducing the preparation time needed for scans. They will also help make the process of scanning individual patients more efficient and minimise a system’s set-up time. Another benefit is that it makes the systems easier to use, allowing providers to maximise the utility they can gain from the systems, despite potential limitations caused by shortages of technicians or inexperienced technicians.

Although there were fewer product announcements for ultrasound, the technologies on show and vendor positioning were also primarily focussed on workflow efficiency. That said, there was also a strong focus on the ever-improving imaging capabilities of ultrasound as an alternative to advanced modalities in certain applications, with continued focus on contrast-enhanced ultrasound imaging, elastography and micro-vascularization assessment. Other key trends were the increased focus on liver imaging, with Siemens Healthineers and Philips launching new liver analysis capabilities, and the increasing infiltration of AI-based features, not only for clinical decision support but also to assist the user during image capture through probe placement guidance, organ detection and automated labelling.

Technician Tailored

Modality vendors at RSNA 2021 were also looking to aid users through hardware improvements. Some technicians suffer from ailments or injuries caused or worsened by their repetitive use of imaging equipment. To this end, vendors have also been focusing on both the ergonomics and useability of systems to address the technician’s as well as the provider’s and patient’s requirements.

Another manifestation of this drive for efficiency materialised in launches of on-scanner AI solutions which helped improve the acquisition of medical images from the advanced modalities. These deep learning-based image reconstruction techniques can dramatically cut the time it takes to acquire MR images. This  reduces both the effective cost of utilising the modality and the time required, diminishing some of the barriers stopping MRI being more broadly used in clinical practice. The higher scanning efficiency also improves the patient experience and enables providers to scan more patients per day. Similar tools for CT imaging also offer the added benefit of reducing the radiation dose patients are exposed to, whilst improving imaging quality, an increasingly important consideration given the growing interest in CT-based screening programmes in some countries.

Among the broader themes in terms of modalities at RSNA was the fact that innovation and developments are increasingly focused around 3D imaging. There are multiple reasons for this, but in essence, these modalities have greater clinical potential, and with the greater level of precision imaging they provide, enable radiologists to make better diagnoses. This is being illustrated with investment being promoted in these modalities. In China, for example CT is forecast to grow significantly over the coming years, with the Chinese government actively prioritising the modality. This prioritisation means that in some markets CT looks set to increasingly take market share away from high-end radiography systems as the cost of CT becomes more affordable.

This will also be facilitated in part by developments such as those seen at RSNA. The major barriers stalling the adoption of MRI and CT are the investment required both in terms of upfront cost and the time investment required to capture and read the images. Advances in software to expedite image capture and analysis will help diminish these barriers, and enable providers to consider MR and CT systems, where they wouldn’t have previously. For vendors, this also represents opportunity. The maturity of the X-ray market in developed countries means that most sales will be on a replacement basis. CT and MRI on the other hand are markets in which growth for new installations is still possible, through systems which are less expensive and resource intensive to purchase, and therefore enable providers to choose the modalities for the first time. This trend is being catered for further by the likes of Siemens and Hyperfine, for example, who are both marketing smaller and lighter systems, that require less extensive infrastructure for them to be installed within smaller hospitals, clinical departments (e.g., orthopaedic, emergency and intensive care) and outpatient centres.

Efficiency Above All

Ultimately, the factor that united the majority of the developments at RSNA was efficiency and allowing providers to do more with less. Whether that meant less expenditure, less infrastructure, less time or less expertise, most of the new developments at the show opened up increased possibilities for providers. In many instances, instead of demonstrating new high-end clinical tools, vendors were showing providers how they could address the incoming backlog of scans within their budget and time limitations.

This, at times, happened in unexpected places. In many instances, the use of AI in medical imaging was expected to aid image analysis. While this is a developing trend and such tools look set to have a dramatic impact in the future, at present AI has had the most success on the scanner rather than in the reading room. One of the reasons for this is that in many instances, it is easier to demonstrate a return on investment for AI based on scanners compared to image analysis systems. Vendors can demonstrate that AI-enhanced systems can reduce scan times, which directly translates to the ability to conduct more scans for providers. On-scanner workflow tools, such as positioning support, intelligent protocolling and automatic image accept and reject meanwhile can offer a clear route to the necessity of fewer rescans, again clearly enabling radiology departments to operate more efficiently.

Problem Solvers

More broadly RSNA 2021 will have been a successful show for most vendors. While there were less attendees, and some initial consternation at the reduced footfall, in the end, the consensus was that it had actually enabled vendors to have more focused conversations. There were fewer conversations to be had, but those that vendors did have with providers would have been with qualified buyers and focused around solving providers’ specific problems of the moment. These problems would have, in many cases, revolved around dealing with the enormous backlog of patients, and attending to them effectively and efficiently. This focus would have allowed vendors to directly address this problem. Vendors’ displays at RSNA showed that they weren’t resting on their laurels, and have been continuously innovating, with, once again, a great deal of focus on the clinical workflow and efficiency that providers need at present.

This year’s conference will have no doubt benefited from the ‘buzz’ that a return to Chicago will have caused, and with providers’ purchasing disrupted over the last two years and an unprecedented volume of patients to be seen in the coming months and years, RSNA 2021 was always going to represent a golden opportunity for vendors. By giving providers what they need, both in terms of the hardware itself and its integration into the workflow, this opportunity has been seized.

 

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