Joe Marion, a principal in the Waukesha, Wis.-based Healthcare Integration Strategies LLC, has participated in 42 RSNA Conferences—probably among the most of any current attendee. No one has a broader perspective on the imaging informatics vendor market than Marion, who spent years on the vendor side before shifting over to consulting a number of years ago.
As in recent past years, Marion sat down at this year’s RSNA Annual Conference, being held at Chicago’s vast McCormick Place Convention Center, and sponsored by the Oak Brook, Ill.-based Radiological Society of North America, on Tuesday afternoon, to speak with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
What’s your overall impression of the exhibit floor at this year’s RSNA?
Well, obviously, the one buzzword that’s everywhere is artificial intelligence. The reality is that I think it means different things to different people. The difference between last year and this year is that some things are coming to fruition; it’s more real. And so some vendors are offering viable solutions. The message I’m hearing from vendors this year is, I have this platform, and if a third party wants to develop an application or I develop an application, or even an academic institution develops a solution, I can run it on my platform. They’re trying to become as vendor-agnostic as possible.
Meanwhile, outside of one vendor, I’m not really seeing a whole lot of emphasis this year on value-based care; that’s disappointing. I don’t know whether people don’t get it or not about value-based care, but the vendors are clearly more focused on AI right now. And that’s surprising to me in terms of some of the mandates, for example, for referring physicians to soon use clinical decision support—that’s important. [Here, Marion referred to the Protecting Access to Medicare Act (PAMA), which requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services—CT, MR, nuclear medicine and PET—for Medicare patients. The federal Centers for Medicare and Medicaid Services (CMS) will progress with a phased rollout of the CDS mandate, as the American College of Radiology (ACR) explains on its website, with voluntary reporting of the use of AUC taking place until December 2019, and mandatory reporting beginning in January 2020.] And I don’t think the imaging marketplace is anywhere prepared to manage value-based care yet.
Meanwhile, we’re seeing ongoing consolidation among vendors: for example, Intelerad has just acquired Clario. [As announced on Nov. 25 in a press release published on Business Wire, the Montreal-based “Intelerad Medical Systems™, a leader in enterprise workflow solutions, today announced the acquisition of Clario Medical, a zero footprint worklist company based in Seattle, Washington. The combined product offering will augment Intelerad's robust and highly scalable enterprise imaging solutions with Clario's rich, zero footprint worklist, satisfying the demanding needs of rapidly growing radiology practices and health systems.”] Clario was the last remaining independent worklist management/workflow company. Medicalis and Primordial had been the last two others, before being acquired by Siemens and Nuance, respectively. So all of that independent workflow capability is gone. But people perceive that even though Medicalis is now a part of Siemens and Primordial is a part of Nuance, that they’re available for third-party applications. They’re viewed as vendor-agnostic solutions, even though they’re part of bigger companies.
Is anyone buying PACS [Picture Archiving and Communications Systems] anymore outside of pure replacement needs?
Probably not. The only real reasons now that people are purchasing PACS systems any longer are replacement or upgrade. The one that’s on fire has been Visage [the Richmond, Victoria, Australia-based Visage Imaging]; they picked up Mayo Clinic last year and so everything in all of Mayo is now running off Visage. They’ve replaced their legacy GE and Siemens systems. They’ve just announced Partners in Massachusetts. So they’re on a roll.
Why is that?
I think people like their product, it’s scalable, and they’ve got a great user interface. It’s a viewing environment, not a complete PACS. They rely on third parties for the archive. They don’t address the vendor-neutral archive, they’re just about the front-end viewing. And they use third parties like Primordial or Medicalis for workflow, and just focus on the viewing aspect.
The other one that’s on fire is Sectra [the Linköping, Sweden-based Sectra AB]. Philips used them for PACS over ten years ago, and when they bought Stentor, they dropped that relationship. But only half of the sites that had Sectra went with Philips, half stayed with Sectra. And they’ve picked up HAP [the University of Pennsylvania Health System] in Philadelphia, and City of Hope in California. They never used to get invited to the table for the big deals. And the University Hospitals in Cleveland is their showcase. And now that they’ve got some of those big university hospitals, for PACS, they’re getting other deals.
So we’re seeing changes in the lead [PACS] vendors in some cases. Visage is a clear example because they’ve had so much success; Sectra is up and coming—they’ve always been strong in mammography, and they’re leveraging a lot of that technology now. Change Healthcare had some issues in terms of that transition from McKesson to change. They haven’t kept pace; but I think they can easily recover. They’re moving, interestingly enough from their dedicated relationships, and they have a relationship with Google and are going exclusively with Google Cloud, so over the next few years, their product line will change considerably. The same is true with Intelerad: they’re pushing heavily into cloud structure, which is why they acquired Clario. IBM has gotten more realistic. They do have a couple of pieces out there that are current, release product. Last year, it was a lot of smoke and mirrors and promises; this year, they legitimately have some products out there.
The fact is that tTe AI market today is like what the PACS market was fifteen years ago—very crowded. There are something like 50 players out there; it will shake out over the next several years.
What will make some succeed and some not?
I think it’s going to be the value of the product, and also the extent to which the vendors will make their products flexible in terms of being interfaced with others, so there’s this integration aspect, folding into vendor A, vendor B, vendor C, etc. So for a third party, the more they reach out and create relationships, the more successful they’ll be. A lot of it will come down to clinical value, though. Watson has had problems in that people have said, it’s great, but where’s the clinical value? So the ones that succeed will be the ones that find the most clinical value.
This is your forty-second RSNA. When you look at the trajectory of last ten years and what’s ahead, what do you see happening in the next few years?
I think the first push of AI right now is in the context that some vendors have described it as enabling the radiologists to become more efficient. That’s the primary, initial set of tools. But that’s the clinical set of tools. The next wave will go beyond the clinical to the operational, making the department more efficient, and being supportive of value-based care.
What should healthcare IT leaders be focused on right now, as they look at this market?
Well, the other aspect of this is that more and more of this technology, on the imaging side, is moving to the cloud. And that’s part of the struggle of this: how are they going to manage that, in terms of security and all the other issues they worry about, while maintaining ownership of their data?
Are there any dangers or cautions for IT leaders to consider in the next few years?
I think the challenge lies in asking how much to focus on the EHR [electronic health record], versus how much to focus on other areas. Some of these cardiology solutions are reporting modules. Cardiology has looked unfavorably on cardiology PACS systems, because they haven’t proven to be full-fledged cardiovascular information systems. Many providers have tried to make cardiology PACS systems work as full cardiovascular information systems. For example, one major EHR system has a cardiology solution that just collects data, but doesn’t manage the images. So the IT people think they’ve got a solution, but from the standpoint of cardiologists, they don’t; it’s not robust enough to serve all their needs. And cardiology has come out of disparate systems, EKG, vascular, ultrasound, a hodgepodge of systems, and no single environment. And over the last ten years, those have evolved to provide a true cardiovascular IS. GE’s done that, Fuji’s been transitioning to that. Lumedx [the Oakland, Calif.-based Lumedx] really has proven itself to be the gold standard in that area; they started with the databases, and then expanded off that to do the reporting; they do the registries. So they have full-service capability. They acquired a PACS vendor. They have a relationship with a vendor for the hemodynamic data.
On a scale of 1 to 10 in terms of optimism versus pessimism, in terms of imaging informatics moving forward to where it needs to go, where would you say you are right now?
I guess I’d say maybe a “6.” One of the things I’ve done is to create a schematic that I’ve been sharing with vendor executives this year on the exhibit floor. It has to do with the integration of various capabilities. On the one hand, you’ve got one set of capabilities that are fairly well established—the modalities, PACS, RIS [radiology information systems], EHRs, and advanced visualization. Then you’ve got emerging capabilities, including analytics, AI, workflow orchestration, CDS [clinical decision support], and referral management. How will vendors integrate all of those capabilities on behalf of their customers?
Every vendor has a slightly different strategy. But for them to succeed, they’ll have to figure out a strategy to enable them to do all of those things, either by themselves or through others. And even as far back as the modalities, people are starting to build AI into the modality. For example the patient moved [residences]; what do I do. Do I have to repeat images or not?
Ultimately, then, vendors will have to move towards a new level of robustness?
Yes, they’ll have to figure all of this out in terms of a changing customer mix. So Advocate [the Downers Grove, Ill.-based Advocate Health Care] and Aurora [the Milwaukee, Wis.-based Aurora Health Care] are now together, for example [on April 2, the two systems merged into a 27-hospital, $11-billion-in-revenues integrated health system, the tenth-largest in the U.S.] And they’re working off two different Epic EHR systems. Advocate concentrated on GE for PACS; Aurora is focused on McKesson/Change for PACS. So how will they contend with that and move forward? If you think of the workflow, why shouldn’t a radiologist sitting in Milwaukee be able to read a case down in Chicago? So because of consolidation, it’s a different picture than five years ago. So the workflow orchestration element is huge. How do I now divvy up that work between Advocate and Aurora? How do I provide the information from the EHR that accompanies the images, to make that information available? The vendors are wrestling with this. They haven’t yet realized that their customer base has changed.