RIS and PACS suppliers – Challenges in Europe
By Uwe Buddrus, Managing Consultant HBS Consulting Gmbh, Leipzig and author of the recently published landmark study on ‘Current Installations and Future Investment Plans for X-ray Equipment in Europe’.
The market and technical development of Radiology Information Systems (RIS) and Picture Archiving and Communication Systems (PACS) solutions has been driven by the increased use of digital imaging equipment such as computed tomography (CT), magnetic resonance imaging (MRI), nuclear medical imaging (NMI), and digital endoscopy and ultrasound. The volume of “data” generated from the explosion in the number of images created by these various modalities has necessitated the need to provide a solution to manage them. Furthermore, the increasing prevalence of networked PCs in hospitals and decreasing electronic storage costs have also aided in the emergence of RIS/PACS solutions. With regards to PACS the ability to manipulate and to make measurements on digital images has also promoted the introduction of these systems in hospitals throughout Europe.
With advancing digitalisation, x-ray equipment, which still constitutes the major part of sales in diagnostic equipment, is a prime target for integration with RIS/PACS.
The following chart provides an overview of the current level of integration of digital x-ray systems (Digital RX) with a PACS or RIS, which is to some extent lower than the overall proportion of hospitals with RIS/PACS installations. The chart is based on data derived from HBS Consulting’s recently completed ‘Assessment of the installed base of Radiography equipment and the future of Computed Radiography (CR) and Direct Radiography (DR) in Europe’.
Source: HBS Consulting - Assessment of the installed base of Radiography equipment and the future of Computed Radiography (CR) and Direct Radiography (DR) in Europe
Although the data is not reflective of the total proportion of hospitals with RIS and/or PACS, it can be clearly seen that country differences in the level of integration exist. The same is true within each country for small and large hospitals – in small hospitals the level of integration is found to be generally lower and similar for RIS and PACS, while the level of integration and the difference between RIS and PACS is considerably higher in large hospitals.
At present RIS are generally more widely established than PACS in all the countries where the research was conducted. The difference ranges from just a minor share of about 10% in Spain and Germany to almost two fifths in France. RIS were usually installed before PACS, which mirrors the development of hospital IT infrastructures, where also administrative functionalities were the basis for later development of more specialised functionalities. The implication is clear: many current installations are stand-alone systems that were integrated with the equipment at different points in time.
The following two charts will provide an overview of future plans regarding RIS and/or PACS installations in acute or general hospitals in some of Europe’s major markets.
The first chart is also based on data derived from the ‘Assessment of the installed base of Radiography equipment and the future of Computed Radiography (CR) and Direct Radiography (DR) in Europe’ and shows the proportion of hospitals with plans to integrate RIS and/or PACS. However, this data is not completely reflective of the total proportion of hospitals with plans for RIS and/or PACS, since these plans were only assessed systematically for hospitals with investment plans in digital equipment.
Source: HBS Consulting - Assessment of the installed base of Radiography equipment and the future of Computed Radiography (CR) and Direct Radiography (DR) in Europe
The planned level of integration with digital x-ray equipment shows great differences between countries (and customer segments) – from almost complete integration in Germany to less than half of the planned digital x-ray installations in France and Italy.
In order to provide a more complete picture of future plans for RIS and/or PACS, preliminary results have been extracted from HBS Consulting’s current research on the status and future direction of European hospital IT development – the HBS/HINE eHospital project (see also the last issue of the HBS Quarterly). The following chart provides an overview of the proportion of hospitals with plans to review the new installation or the replacement of an existing RIS and/or PACS.
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Note: the UK sample at the point of preliminary evaluation was still too small for more than indicative data! Source: preliminary evaluation of data from the HBS/HINE eHospital project
Integration vs replacement
The above charts show that the overall proportion of hospitals planning to review the installation or replacement of a RIS and/or PACS is generally higher than the proportion of hospitals planning the integration of digital x-ray equipment with RIS and/or PACS. As previously stated, not all digital x-ray equipment is planned to be integrated with RIS and/or PACS. In conclusion, the installation of a RIS and/or PACS is still driven to a significant degree by other digital imaging equipment such as CT, MRI, NMI, etc.
It can also be noted that generally more future plans refer to PACS than to RIS, which indicates that hospitals now strive to reduce the need for storage space, improve image handling and to eradicate the use of expensive film and harmful chemicals used in the production of X-ray images.
It is clear that a significant number of hospitals will invest in RIS and/or PACS over the next three years but, as the following chart shows, the decisions regarding the preferred supplier are not firmly in the direction of any specific company. This is most likely indicative of the fact that the change in offerings will mean that the buyer needs to assess at the appropriate time the best system.
Note: the UK sample at the point of preliminary evaluation was still too small for more than indicative data! Source: preliminary evaluation of data from the HBS/HINE eHospital project
A key question to be addressed by any supplier of RIS and/or PACS solutions should therefore be what criteria most influence the supplier selection by potential customers.
Clearly of core relevance to the vast majority of customers is that both systems are part of an integrated solution, e.g. a suite of products. This was clearly confirmed by both of HBS Consulting’s studies and thus by end users in radiography departments as well as in IT functions.
The following chart provides an overview of the preliminary results regarding this issue from the HBS/HINE eHospital project.
Note: the UK sample at the point of preliminary evaluation was still too small for more than indicative data! Source: preliminary evaluation of data from the HBS/HINE eHospital project
Among the key arguments given by potential clients for the preference of an integrated solution are the perception that only this can achieve ‘optimal workflow improvement’, ‘easier and faster access to patient and image information across the hospital’, and user friendliness through ‘a single user interface’ and ‘practical and easy use without the need for too many manuals’. There are few arguments in favour of stand-alone solutions, which include ‘more flexibility also with regards to supplier choice’ and ‘sufficient for small hospitals’.
In conclusion, even if a supplier can ensure full compatibility with other stand-alone solutions or existing RIS, hospitals will preferably choose an integrated solution or suite.
However, there are other factors that will also have a major impact on supplier selection. HBS Consulting has also assessed openly what advice customers would give RIS and PACS suppliers in order to fulfill customer needs better. The results across all countries are presented in the following chart.
Source: HBSConsulting - Assessment of the installed base of Radiography equipment and the future of Computed Radiography (CR) and Direct Radiography (DR) in Europe
The above chart shows clearly that service and support delivery, followed by product improvements and orientation on customer needs are the top three key requirements in supplier selection. That these topics were most frequently mentioned as an advice to RIS/PACS suppliers implies that there is still room for improvement in these areas. The same is true for pricing. At current pricing levels customers do not believe that the systems which they purchase is currently deliver adequate value for money.
It should be noted that country differences exist, as the following chart shows.
Source: HBS Consulting
In Germany service and support is a key requirement, but an objective pre-sale assessment of the customer needs is also often missed. End users in the UK, France and Spain complain most about the continually inadequate user friendliness and compatibility of systems, which makes the request for product improvements the largest category of advice in these countries. Italian hospitals require price decreases most often, but at the same time also echo the desire for adequate levels of service and support.
Improvements or requests in service support encompass primarily better after-sales contact, e.g. a dedicated contact person, continuous maintenance and reliable 24/7 break and fix support.
Product improvements circle around reliability, compatibility with other systems and user friendliness in terms of intuitive (and possibly personalised) user interfaces and access speed (e.g. easy log-in). French users also demand a larger storage capacity.
Improved product information and orientation on customer needs refers to the notion that sales representatives are often not knowledgable enough about the requirements of the actual end users and therefore fail to match customer needs with their products’ functionalities and capabilities. To a lesser degree it is even felt that some sales reps provide wrong information. As a result, end users felt the solution to be too complex or inadequate for their daily work.
In this context, it is a requirement that sales reps also speak to end users, assess the situation in the radiography rooms, and demonstrate how the solution can fulfil the assessed requirements. In other words ‘listen to what is needed and mould the installation according to the specific site’.
‘Providers need to be realistic concerning their system and what it can really do; providers claim too much - honesty and integrity is important!’
In terms of price improvements, transparent pricing would be a first step in the right direction. Customers will be more willing to accept a price currently felt as unjustified, if they are made aware of the value to be derived from the product. At present, price competition is not expected to necessarily have an impact on product and service quality.
The request for more end user training could be considered as part of after-sales s ervice and support since it is not only required initially after installation, but should be offered as a continuous and ongoing service. A frequent recommendation is to offer the initial training as part of the sale, and ongoing training as part of a service package.
In summary, the clear message is that a winning supplier will have to offer a software suite that encompasses all functionalities required in the radiography department or even better across the hospital. It is fair to assume that integrator engines offering full system integration with single user interfaces and unrestricted information flow will be equally accepted. Providers of stand-alone solutions will however find an increasingly difficult market place to compete in. Additionally, customers will select their supplier based on an honest and transparent matching of customer needs with product functionalities and the proven ability to deliver excellent after sales support.
HBS Consulting has assessed the current level of RIS and PACS integration of digital x-ray equipment and the future plans for such integration in two European-wide landmark studies each involving a statistically relevant sample of about 900 acute or general hospitals across the countries under review. The data related to RIS and PACS from these studies will be amalgamated into a report on the ‘Current Installations and Future Investment Plans for RIS and PACS in European Hospitals’, which will be made available in August 2004.