A patient visits her primary care physician. The doctor pulls out his stethoscope. He listens. But he can’t actually see anything. Primary care physicians have the tools of blind people – a big issue in health care right now, according to Paul Mullen, GE Healthcare’s chief marketing officer for ultrasound.

“The concept of a personal ultrasound device where it can give eyes to blind doctors is really an important thing to consider,” he says.

Although our “blind” physicians may have a long way to go, ultrasound has advanced in leaps and bounds in only a short time period. Over the past 15 years, Glenn Davis’ wife has given birth to five daughters in several different countries, including: Australia, England, Singapore and the United States.



“I have seen the evolution from what was originally a very granular type of image in ultrasound, in comparison to the current stunning ultrasound imagery available,” says Davis, VP of worldwide marketing and sales for ultrasound at Siemens Healthcare. “Today’s ultrasound enables you to see in three dimensions; you can see the face and profile and even rotate the image.”

Ultrasound is the fastest, strongest growing modality worldwide and there is no sign of it slowing down. Over the next few years, ultrasound will see continued growth in not only the traditional markets, but its utilization in radiology and cardiology will also continue to increase in the major markets of Europe, Asia and the U.S., according to Davis.

This year, ultrasound sales are predicted to surpass $4.8 billion and reach more than $6 billion by 2017 at an estimated CAGR of 5 percent, states a March report by Transparency Market Research. Meanwhile, the ultrasound market increased by 13 percent in 2011, with the majority of growth occurring in premium segments, explains Maher Elhihi, senior manager, market development for ultrasound at Toshiba America Medical Systems. New users account for much of this growth.

“One out of seven of the people who bought an ultrasound from GE last year wasn’t an ultrasound user ten years ago,” says Mullen. “They weren’t even in the ultrasound market; they weren’t a user; they didn’t think about it; they couldn’t even spell ‘ultrasound’. You’d have to look long and hard to find a similar sort of uptake in a business to business space.”

So where are these new users coming from? Mullen believes they are coming, in part, from new applications. “When I started in ultrasound, it was radiologists, cardiologists and OB/GYN,” he says. “Now it is rheumatologists, urologists, surgical guys, critical care doctors, ER doctors and the list goes on and on in terms of new users learning to apply ultrasound to their craft.”

Ultrasound’s rising popularity can be attributed to the fact that it is actually a very immature technology, according to Mullen. While this might seem like a negative, the technology’s immaturity is actually leading to substantial improvements in clinical outcomes.

“Every year, ultrasound is better than it was before in a really dramatic way,” says Mullen. “Even comparing ultrasound images from this year and two years ago, the difference is clear.”

Driving demand for ultrasound is an increase in research and development, low costs for health care services fueling medical tourism growth, foreign investments in the health care sector, and a rise in the number of people suffering from chronic diseases that require early diagnosis via ultrasound.

Even amidst the gloomy economy, ultrasound is thriving. Some health care facilities are specifically updating their ultrasound portfolios to get ready for health care reform’s anticipated repercussions.

“Contrary to the rest of the health care environment where we are seeing hospitals freezing up their assets for purchasing heavy iron, we are still seeing growth in ultrasound, says Elhihi. “Although the number of ultrasound systems grew in 2011, we are not seeing a huge increase in the number of procedures ultrasound is used for. This is because people are getting ready for [the Patient Protection and Affordable Care Act], and with it, a large influx of people that will come into the hospital.”

Unsurprisingly, the sector is rife with competition, but even though competition is fierce, there are fewer and fewer companies fighting for customers due to a high rate of consolidation. Fuji bought Sonosite; South Korean ultrasound manufacturer Medison Co. was purchased by Samsung. In the meantime, smaller companies on the market are also getting ready for acquisition.

“There are just too many competitors out there,” says Elhihi. “In the next couple of years, there will be further consolidation in the ultrasound market.”

The low-cost, flexibility and safety of ultrasound will further increase future adoption into new markets, replacing current medical imaging standards and setting new ones, according to Stephen Holloway, market analyst for research firm InMedica.

“For many physicians, it is no longer a question of ‘why use ultrasound?’ rather a question of ‘when and how can I use ultrasound?’” says Holloway.

Pocket-sized ultrasound machines
Portable ultrasounds are increasingly called on to combat financial and spatial constraints. However, evolving technologies, while seeming to hold promise, are not proving practical for most providers just yet.

“On one hand, a new system might feature the portability a provider seeks, but may not perform quite at the level required by every day, high volume use,” says Christopher McHan, president of Neusoft Medical Systems USA.

Still, systems are getting smaller and smaller. In 2007, Siemens Healthcare released the first pocket-sized ultrasound product – the ACUSON P10. More recently, GE Healthcare’s Vscan and Mobisante’s new smartphone ultrasound product – the MobiUS system -- has re-ignited the debate about pocket ultrasound systems, according to Holloway.

“The smaller machines are getting better all the time,” says Keith Rubenstein, managing partner, VP of sales and marketing, MedPro Imaging, a company that sells new and refurbished ultrasound systems and transducers. “You can pack so much technology into a smaller package. I bet the Philips CX50 could go up against any of the large 400 plus pound systems and give it a run for its money at a fraction of the price.”

Compatible with Toshiba TG01 smartphones, the MobiUS system costs $7,495. Meanwhile, GE’s Vscan, another handheld smartphone ultrasound device, has a ticket price of $7,900. These systems are shaking things up in the industry, as most ultrasound systems can run anywhere from $125,000 to $250,000. But the competition doesn’t seem to be worried.

“Our competitors have tried pocket-sized ultrasound, but they are not doing well,” says Elhihi. “The vision is that pocket-sized ultrasound will eventually replace the stethoscope, but with the current pricing structure, that will be difficult.”

The cost of a hand-held ultrasound machine is still considered a bit steep for the average family practice physician or office-based physician. To counteract this, OEMs are giving away the hand-held systems with other system sales, but they are still not being embraced by a high enough percentage of the target market.

Transmitting images via cellular networks, like the Mobisante systems, makes teleradiology consulting in remote locations possible where specialists are sparse.

“It is clear that the advance of teleradiology, imaging sharing and health care IT integration is a compelling argument that [indicates] future ultrasound devices will need to be compact, mobile and flexible; and perhaps combine cellular, wireless or Bluetooth connectivity,” says Holloway. “The challenge now for suppliers is to bring these features together in one adaptable platform.”

That platform is likely to be a “hybrid” tablet system, as opposed to a smartphone, due to the logistics, user-interface and screen size, which prevent all but basic imaging, Holloway explains.

Affordability’s cost: The pros and cons
Along with lower-priced miniaturized systems, features once only available in high-end ultrasound devices are beginning to appear in more affordable ultrasound devices.

“Adaptive color doppler, pulse inversion harmonic imaging, and panoramic imaging, to name just a few, are now available at far more affordable costs than previously thought possible,” says McHan. “Cost effectiveness and ease of usage will still remain the primary drivers of system selection.”

OEMs like Siemens are trying to develop cost-effective ultrasound products for both the high-end and entry-level customers.

“Not everyone has access to the NYUs or the Massachusetts General Hospitals of the world,” says Siemens’ Davis.

The affordability of new ultrasound systems has increased so much that refurbished systems have seen a downward trend, according to Michael Sweeney, service technician for National Ultrasound, a company that sells new and refurbished ultrasound equipment. And Sweeney believes this trend is set to continue.

“Ultimately, the cost between maintaining a refurbished system and buying a new system makes the decision,” he says. “I think there is going to be a bigger shift towards new and portable and 3-D and 4-D systems as well; this is because cost is going to continue to go down, and more technology and competition are going to come into play.”

The industry’s price cuts are also posing a threat to organizations focused on field service of the equipment, as OEMs continue to drop their prices to service different modalities. “It is hard to have a compelling reason to go with a firm that is more money than the OEM or even close in price,” says Medpro’s Rubenstein.

Expansion to other modalities
A patient has a suspicious spot on his liver and the doctor is in charge of determining whether or not it is a malignant tumor. Up until now, the standard of care had been to diagnose a case like this using a CT scanner. A needle would be inserted into the patient’s belly and directed toward the tumor. If the needle wasn’t on target — a common dilemma — another CT would be required. So, the steps would be repeated, maybe three or four times until the needle finds the tumor and a sample taken. Meanwhile, the patient received four CTs, and equipment and staff was tied up for an hour administering the biopsy. Today, more hospitals offer equipment which enables health care professionals to fuse an image between the CT and ultrasound to guide the needle.

“That reduces the time down to 15 minutes in the ultrasound lab,” says Mullen. “Not to mention, it is also less traumatic for the patient.”

Scenarios like this showcase the myriad of advantages ultrasound has in conjunction with or as an alternative to other imaging modalities that are not only pricier, but may also expose the patient to radiation dose.

Fusion imaging with MRI and CT imaging has also been optimized; by simplifying and semi-automating the fusion process, advanced feature sets are becoming user-focused, a trend sure to drive greater use, according to Holloway. For example, Smart Fusion, a feature available on Toshiba’s Aplio 500, allows health care professionals to call up a prior CT exam onto the ultrasound and synch the two.

“This not only improves your diagnostic confidence, because you are fusing two modalities together, but it also provides an excellent way to utilize interventional procedures to follow up from patient studies,” says Siemens’ Davis. “The benefits of fusion imaging include less radiation dosage to the patient, because you can use ultrasound, and it improves patient care. This goes with the general trend of hybridization of modalities.”

Elhihi believes that most hospitals can actually take 20 to 30 percent of their CT biopsies and move them over to ultrasound.

“We are seeing different emerging applications, especially given the new health care reform and the economic climate, where ultrasound is being seen as the modality to use first,” he says. “If need be, doctors will then expand to CT or MR.”

Ultrasound’s new frontiers
There has been a large growth of ultrasound outside of the traditional markets of radiology, cardiology and OB/GYN, with its utilization increasing among emergency medical physicians, anesthesiologists and critical care environments. These emerging markets are sprouting quickly.

“I just came back from AIUM, which ten years ago was dominated by radiologists,” says Elhihi. “Now only 40 percent of membership is radiology, with the remaining 60 percent coming from other specialties – many of them didn’t exist ten years ago.”

Most of Ultrasonix’s customers are in emerging market segments at point-of-care where ultrasound is used for guidance and fast assessments, according to Neena Rahemtulla, the company’s director of marketing. In emerging economies, ultrasound is used in a shared services model. For applications like musculoskeletal medicine, ultrasound is a new tool for many physicians gaining firsthand experience as to the value of ultrasound guided procedures.

“Increased use in musculoskeletal applications, ranging from sports medicine to rheumatology, is already occurring,” says Holloway. “Rapid assessment of sports injuries using compact systems is being widely publicized by suppliers, most notably for use in the American Football League (NFL) and London 2012 Olympics. Here, and in other new applications, is physician education most vital.”

Carticept Medical has partnered with SonoSite to market ultrasound to the orthopedic market to enable real-time diagnosis of musculoskeletal impairments and to improve the reliability of drug delivery to orthopedic patients. The company’s Navigator Delivery System combines ultrasound technology with an automated drug injection system to increase the efficiency, accuracy and safety of administering pain-relieving medications for joint pain.

“Ultrasound has significant growth potential in the musculoskeletal market, because it offers benefits to both patients and health care practitioners,” says Timothy Patrick, president and CEO of Carticept Medical.

Not only is ultrasound helping orthopedic and sports medicine specialists diagnose musculoskeletal injuries like sports injuries, and impairments like arthritis, but it is helping to improve accuracy for pain relieving local injections. Data published in the American Journal of Sports Medicine last January demonstrated that the use of ultrasound imaging improves accuracy rates in joint injections.

Further to this, ultrasound is proving to be a better imaging modality than mammography for patients with dense breasts, says Rahemtulla. Ultrasonix has just introduced an automated breast ultrasound imaging system – SonixEmbrace -- for research applications. This system can image a breast faster than freehand ultrasound and the results are reproducible – that is, the scans don’t vary depending on who is doing the scanning.

“Adoption is unlikely to happen overnight, and without long-term, robust clinical studies underpinning its use,” says Holloway. “But with improving image quality, increasing automation, low cost and a clear safety record, ultrasound has the potential to replace mammography as the future of breast screening.”

Yet, despite its obvious wealth of benefits, many radiologists regard ultrasound as inferior to advanced imaging modalities like MRI and CT, according to Holloway. In March, the American Institute of Ultrasound in Medicine launched Ultrasound First, an initiative designed to call attention to ultrasound’s safety, effectiveness and affordability. It focuses on educating health care workers, medical educators, insurers, and patients on the benefits of ultrasound in medical care.

DOTmed Registered Ultrasound - May 2012 Companies

Names in boldface are Premium Listings.
Domestic
Doug Anderson, DGA Medical,LLC, AZ
Jay Schermer, Apex Imaging Corporation, CA
Ricardo Armenta, Ultra Solutions Inc., CA
DOTmed Certified
DOTmed 100
Steven Kelley, United Medical Instruments, CA
DOTmed Certified
Diane Hernandez, Nova Technologies, Inc., CO
DOTmed Certified
DOTmed 100
Robert Guyton, Manifest Medical, FL
Grant Norris, Associated Imaging Services, KS
DOTmed Certified
DOTmed 100
John Gladstein, Medical Device Depot, MD
DOTmed Certified
Robert Harris, Imaging Associates Inc., NC
DOTmed Certified
DOTmed 100
Alison Fortin, Global Inventory Management LLC, NH
DOTmed Certified
Bill Cowan, Liberty Diagnostic Services, NJ
DOTmed Certified
Lawrence Maroney, Integris Equipment, NY
DOTmed Certified
Leon Gugel, Metropolis International, NY
DOTmed Certified
DOTmed 100
Kristin Tyke, MEDRAD, Inc., PA
Keith Rubenstein, MedPro Imaging, Inc., WI
Darren Smith, UltraLinq Healthcare Solutions, NY
Raymond Wtulich, Hitachi Medical Systems America, OH
Katie Heineman, MEDRAD, Inc., PA
Christopher Mchan, Neusoft Medical Systems USA Inc., TX
Mike Sweeney, National Ultrasound, GA
Lisa Wiggs, Absolute Imaging Solutions, NC
Maher Elhihi, Toshiba America Medical Systems, CA
Patrick Hardy, Dietz Healthcare, AZ
DOTmed Certified
DOTmed 100
Darlene Benavidez, Better Imaging Solutions, Inc., AZ
DOTmed Certified
DOTmed 100
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
John Pereira, United Medical Technologies, FL
DOTmed Certified
DOTmed 100
Mark Asmer, MedCorp, FL
DOTmed Certified
DOTmed 100
Lamar Gale, Gale Medical, GA
DOTmed Certified
DOTmed 100
Grant Norris, Associated Imaging Services, KS
DOTmed Certified
DOTmed 100
Tony Orlando, Complete Medical Services, MI
DOTmed Certified
DOTmed 100
Robert Manetta, Nationwide Imaging Services, Inc., NJ
DOTmed Certified
DOTmed 100
George Hryshchuk, Advanced Ultrasound Electronics, OK
DOTmed Certified
DOTmed 100
Kenn Matayor, Jaken Medical Inc., CA
DOTmed Certified
Loc Le, All Imaging Systems, CA
DOTmed Certified
Woody Peters, Amber Diagnostics, FL
DOTmed Certified
Monte Montain, Alternative Source Medical, IL
DOTmed Certified
Scott Mattfeld, Authorized Acquisitions LLC, IL
Beau White, Advanced Imaging Healthcare, IN
DOTmed Certified
Colin Grady, GE - Ambassador, IN
DOTmed Certified
Davyn McGuire, MedExchange International, MA
DOTmed Certified
Bob Gaw, PRN, MA
DOTmed Certified
Gary Titov, High Technology, MA
DOTmed Certified
Doug Updike, Priority Medical, TN
DOTmed Certified
Curt Hagg, Vivid Imaging, VA
DOTmed Certified
Mazi Zarrin, Northwest Ultrasound Inc., WA
DOTmed 100
Charlie Jahnke, MedPro Imaging, inc., WI
DOTmed Certified

International
Mads Vittrup, AGITO Medical, Denmark
DOTmed 100
Alex Gagoski, Labteh, Macedonia
FRANCISCO FREIRE, OLYMTOS, Ecuador
xiaohua xu, suomatong medical ltd., China
Welshen Gao, DODODO Medical Equipment Service Co., Ltd., China
DOTmed 100
Niranjan Kumar, India Ultrasound, India
DOTmed Certified
DOTmed 100
kim sung rak, MEDEX, South Korea
DOTmed Certified
PRAMOD MALHOTRA, MEDILINK TECHNOLOGIES, India
Istvan Sesztak, Hun.MED Ltd, Hungary
David Lapenat, ANDA Medical, Inc., Canada
DOTmed Certified
DOTmed 100
Michele Debain, Supersonic Imagine, France
Danielle McCallum, Ultrasonix Medical Corporation, Canada