Advanced visualization (AV) software and clinical applications are essential in the interpretation workflow of computed tomography (CT) and magnetic resonance imaging (MRI). In the last few years, the market success of new premium scanners has also hinged on the availability of wide-set clinical applications modules and image analytics tools, such as quantification, computer-assisted diagnosis and image fusion.
Furthermore, market demand for having this entire solution set accessible as a single, integrated multimodality, multivendor, multiPACS, multiuser and multisite solution that can be deployed in varying “flavors” in and beyond the primary reading room is on the rise. The market is starting to demand a true multidepartment solution as well, which includes all the applications needed for reading various types of exams, such as cardiovascular and oncology applications.
Advances With Multispecialty Clinical Applications
CT continues to attract the larger share of research and development efforts in the AV industry, with MR in a strong second place, followed by positron emission tomography (PET/CT) and nuclear medicine, mainly represented by single-photon emission computed tomography (SPECT). Mirroring the technology and market advances of hybrid imaging systems, notably PET/CT and PET/MR, multimodality image fusion is on the rise as well. Innovations with evermore powerful clinical application “nuts and bolts” are appearing in every area where these modalities are evolving, such as radiology, cardiology, image-guided surgery, neurology, orthopedics and oncology.
Consolidation Around Five Key Industry Vendors
The industry dynamics prevailing in the United States three to five years ago pointed toward the possibility of further industry fragmentation. Many relatively new contenders were actively working to break into the market — vendors with a strong market presence in Japan, such as Aze and Ziosoft, as well as those with innovative thin client solutions, such as Visage Imaging and Calgary Scientific, to name only a few players within these then-emerging competitive tiers. However, this industry fragmentation did not take place in the United States.
On the contrary, the competitive landscape for the U.S. AV market has since continued to consolidate around five major players. GE Healthcare, Siemens Healthcare, Philips Healthcare, Vital Images (now Vital, a Toshiba Medical Systems Group company) and TeraRecon have all continued to gain ground in the U.S. market while upgrading their several-hundred customer bases to their new-generation platforms.
Intensifying Competitive Dynamics Raising Entry Barriers
Stong Japan-based vendors have not achieved the wide impact in the U.S. market. Ziosoft, which became Qi Imaging in 2011, as well as Aze have both had difficulty repeating their success in Japan in the U.S. market.
However, it is important to note Japan’s significance in the global AV market, as the country boasts the highest utilization rates of advanced imaging and quantity of advanced imaging equipment per capita. These varying levels of global market success are due to very different AV workflows in each region. Imaging providers in Japan, and even more so in Europe, rely on radiologists themselves to perform the post-processing manipulations using sophisticated and often cumbersome image analytics tools. Contrastingly, in the United States, much of this work is done by technologists, often as part of 3-D labs, before pushing the reconstructions to PACS for radiologist interpretation, and then billed separately.
Similarly, the other tier of contenders, including Visage and Calgary, has been much more IT-focused in recent years. They developed new universal viewers, which include 3-D/4-D capabilities designed for enterprise-wide deployment.
Industry-wide Alignment With Enterprise IT Deployment
With these ongoing competitive trends, the market activity in the United States can be categorized according to the IT deployment model of new systems, based on three main categories.
The first category, which symbolizes the first-generation of these systems throughout the last two decades, consists of the sale of stand-alone workstations attached to individual imaging equipment or to multiple pieces of equipment of the same imaging modality, such as multiple CT scanners.
The second category consists of AV functionality that is integrated with or embedded into PACS, generally through a partnership between the PACS vendor and one of the AV independent software vendors (ISV). Indeed very few PACS vendors, notably Carestream Health, have developed native 3-D/4-D imaging capabilities embedded into their PACS.
Finally, the third category consists of enterprise platforms based on a server-client architecture, which centralizes the heavy-lifting data processing resources on the server side instead of each individual workstation. Five years ago TeraRecon was the only vendor doing most of its business activity in this segment. At that time, Vital Images joined the segment with its Vitrea Enterprise solution. They were followed by the three major original equipment manufacturers (OEMs) — GE, Siemens and Philips — over the last four years.
Blurring the Lines Between OEM and ISV
Since then, OEMs have made impressive strides developing and marketing their enterprise products, which now includes GE’s Advantage Workstation (AW) in its server configurations, Siemens’ syngo.via and Philips’ IntelliSpace Portal.
These vendors are gradually bringing more of their clinical applications to their enterprise product in order to expand their offering, which, in general, still lacks the breadth of their thick client workstation offerings. In addition, initial research suggests that Philips has developed an edge over the other two vendors, using a single server for all three of the core imaging modalities — CT, MR and nuclear — as opposed to interconnecting two or more servers to achieve a multimodality AV platform.
While they continue to conduct a significant portion of their business activity in the first segment — leveraging new modality sales for new workstation sales — the OEMs’ recent advances with the server-client deployment model (the second and third segments) are even more significant. Today, they are able to position their enterprise product as a true vendor neutral platform, a competitive advantage.
Comparison Chart
This article served as an introduction for a comparison chart of advanced visualization software. Click on the comparison chart tab at the top of the page to access the online version of the chart. Participating companies include:
Agfa
www.agfahealthcare.com
www.agfahealthcare.com
Aycan
www.aycan.com
Fujifilm
www.fujimed.com
GE Healthcare
www.gehealthcare.com
Philips Healthcare
www.usa.philips.com/healthcare
Pie Medical Imaging
www.piemedicalimaging.com
Siemens Medical
www.healthcare.siemens.com
TeraRecon
www.terarecon.com
Vital Images
www.vitalimages.com
Editor’s note: Nadim Michel Daher is a principal analyst with Frost & Sullivan’s advanced medical technologies practice. His knowledge base covers radiology and cardiology informatics and imaging equipment across modalities.
May 12, 2020 
