GE Healthcare and FS Mobile Asset Management White Paper

Reduce Your Cost Whilst Improving Patient Care &
Satisfaction: Inefficient Use of Mobile Assets is Costing

Australian Hospitals more than $60 million a year
A Frost & Sullivan White Paper

in collaboration with GE Healthcare
www.frost.com
Reduce your costs whilst improving patient care and satisfaction
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I. Executive Summary.............................................................................................................................. 3
II. About this White Paper.........................................................................................................................5
III. Definitions........................................................................................................................................... 6
IV. Public Hospital Expenditure in Australia............................................................................................. 7
V. The Cost of Inefficient Mobile Asset Management..............................................................................9
VI. Current Processes for Managing Mobile Assets................................................................................12
VII. Costs Associated with Mobile Asset Management.........................................................................15
VIII. Other Costs Associated with Inefficient Mobile Asset Management............................................. 23
IX. The patient experience is impacted................................................................................................. 29
X. Adoption of Mobile Asset Management Solutions............................................................................ 31
XI. Systems and Processes to Cut Through the Clutter........................................................................ 34
XII. Appendix......................................................................................................................................... 38
Contact.................................................................................................................................................. 38
Legal Disclaimer......................................................................................................................................39
CONTENTS
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I. EXECUTIVE SUMMARY
Inefficient use of mobile assets is a crucial
issue in the Australian hospital system,
resulting in higher costs, inefficiencies in
patient care, and poor patient experiences.
Mobile assets (such as infusion pumps,
oxygen cylinders, intra-venous (IV)
pumps, ventilators/breathing devices, and
pulse oximeters) are increasingly used in
Australian hospitals as an integral part of the
Public hospitals in Australia spend as much

as $250 million a year on buying, renting
and maintaining mobile assets. Inefficient
management of these mobile assets cost
hospitals around $64 million each year.
Table 1: Impact of Inefficient Mobile Asset

Management at Australian Public Hospitals
Key Concern
Impact
Daily loss in patient

care time
32,500 hours
Over-purchased
mobile assets
$16 million per year
Inventory
replacement
costs from loss or
mishandling
Under-utilisation of
mobile assets
Other concerns
Delays in admissions,
treatment start times
or discharges
patient care process. Many of these devices

are utilised in multiple areas of hospitals,
and shared across different wards and
departments.
However, in many hospitals across Australia
mobile assets are being ineffectively utilised.
Few hospitals have tracking or location
systems in place for mobile devices, and
the inability to locate the devices when
needed is creating significant inefficiencies
in hospital operations, with a major impact
on operating costs.
Source:
Frost & Sullivan research.
Based on data from 2013.
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Frost & Sullivan research has identified that:
With the mounting cost pressures on healthcare
The average number of mobile devices used
delivery in Australia, wastage resulting from inefficient
in hospitals (currently about eight per bed in
mobile asset management is an unacceptable
general wards) is increasing every year;
cost burden on the public healthcare system.
The average total value of mobile devices in use

(currently about $3,000 per bed in general
Many hospitals have not defined adequate
wards) is escalating every year;
processes and workflows that align their services
The average utilisation of mobile assets is 50%
with device usage. Few hospitals have identified
to 60%, far below the optimum level hospitals
the resources that can potentially be shared across
can potentially achieve;
cost centres to help reduce inventory. Likewise,
Hospital staff are often unable to locate mobile
few deploy technology systems on top of their
assets when needed;
business processes that provide real-time tracking
Nurses spend an average of about half an
of mobile devices, to enable time- and cost-
hour per shift to locate mobile assets, which
efficient collaboration and resource-sharing across
impacts patient care; and
their services.
Around 10% of mobile assets need to be

replaced annually due to loss or mishandling
While there is growing awareness of the impact
of devices.
of under-utilisation of mobile assets on costs,

workflow efficiency, and quality of care, factors
Frost & Sullivan estimates that public hospitals
such as budget constraints and uncertainty about
in Australia are wasting more than $60 million
the potential benefits of asset management and
per year as a result of inefficient management
tracking solutions restrict their adoption.
of mobile assets. In addition, approximately

32,500 hours of patient care time are lost due to
medical staff trying to find mobile assets. There
are other non-quantifiable consequences such as
delays in admission or treatment start times, or in
discharge procedures.
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II. ABOUT THIS WHITE PAPER

Australian hospitals have generally been early
adopters of digital healthcare solutions. An important
aspect of hospital workflows is the management
of mobile assets and their associated costs. The
objective of this white paper is to assess the impact
of current mobile asset management practices and
technology solutions at Australian public hospitals
on healthcare costs, staff productivity, and patient
experience. The report also aims to identify areas
of improvement, focusing on both technologies
and processes that could deliver real value to
healthcare providers.
A combination of primary and secondary research
This white paper is based on 20 discussions and
has been used to understand the spending
one forum with representatives from Australian
trends across Australian public hospitals, and
public hospitals to obtain their views on asset
the effect of mobile assets on overall costs.
management practices at their facilities. In order to
Frost & Sullivan has assessed the asset management
ensure fair representation from relevant stakeholder
and tracking solutions currently being used to arrive
groups, discussions were conducted with end users,
at an objective opinion on the level of market and
including nurse unit managers and heads of nursing,
technology development.
as well as hospital decision-makers including

biomedical engineers, asset managers, finance
managers, and C-suite executives. Data used in this
white paper was provided by hospitals based on
their 2012-2013 financial year. All expenditure, cost
and revenue figures are stated in Australian dollars
unless mentioned otherwise.
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II. DEFINITIONS
Hospital inventories include a wide range of medical
Utilisation of mobile assets is defined as the number
devices, from heavy-duty, expensive capital
of devices in use at a given point in time. While
equipment to less expensive portable devices
under-utilisation of mobile assets indicates that the
and consumables. Mobile assets include infusion
entire inventory of mobile assets at a hospital is not
pumps, oxygen cylinders, IV pumps, ventilators/
being used to its full capacity.
breathing devices, pulse oximeters, continuous

veno venous hemofiltration (CVVH) machines,
Mobile asset management refers to the procedures
sequential compression devices, crash carts,
and practices implemented at a hospital to ensure
isolation carts, vital signs monitors, hypothermia
efficient utilisation of mobile devices, in a manner
units, beds, specialty beds, stretchers, wheel chairs,
that reduces costs and improves the quality of
specialty wheel chairs, telemetry units, and mobile
patient care. This includes maintaining appropriate
work stations. Most of these devices are not fixed
inventory levels, ensuring adequate but not
to a particular department or area, and tend to be
excessive usage, providing the right devices at
used in multiple departments.
the right place and the right time, and recording

maintenance and replacement schedules as well
as costs of devices.
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IV. PUBLIC HOSPITAL EXPENDITURE IN AUSTRALIA

The quality of healthcare is no longer only evaluated in terms of improvements in population health and
clinical outcomes. Sustainability and efficiency of healthcare delivery are emerging as important parameters
in assessing the success of a healthcare system. In 2013, Australia was ranked 7th globally in terms of the
efficiency of its healthcare system, based on life expectancy and the relative and absolute per capita cost
of care.1 Australia spends significantly more per capita on healthcare than other developed Asia-Pacific
economies. While Australias universal health system has delivered significant benefits over the past three
decades, the country now faces increasing challenges in managing healthcare costs due to an ageing
population, higher incidences of chronic diseases, and the escalating costs of advanced pharmaceuticals
and medical equipment.
Health expenditure is increasing inexorably, placing a bigger burden on both consumers and governments.
Healthcare expenditure in Australia was $140.2 billion in 2011-2012, or 9.5% of GDP, compared to 9.3%
of GDP in 2010-2011. In the past five years, healthcare expenditure has surged by over 35%. Government
healthcare expenditure, which accounts for nearly 70% of total expenditure, has increased by almost 38%
over the past five years placing an increasingly unsustainable financial burden on public spending.2
Figure 1: Healthcare Expenditure in Australia, 2007-2008 to 2011-2012

Expenditure
($ Mn)
160,000
120,000
80,000
40,000
0
2007 - 08
2008 - 09
2009 - 10
2010 - 11
2011 - 12
Private Expenditure ($ Mn)
32,411
35,098
36,506
40,202
42,426
Government Expenditure ($ Mn)
71,152
78,563
84,847
90,108
97,815
Total Healthcare Expenditure ($ Mn)
103,563
113,661
121,353
130,310
140,241
Source: Australian Institute of Health and Welfare (AIHW)
Bloomberg Visual Data, Bloomberg Best (and Worst): Most Efficient Health Care: Countries http://www.bloomberg.com/visual-data/
best-and-worst/most-efficient-health-care-countries
2
Australian Institute of Health and Welfare, Health Expenditure Australia 2011-12, http://www.aihw.gov.au/publicationdetail/?id=60129544658 (25 Sept 2013)
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Hospital expenditure can be categorised into capital expenditure and recurrent or operating expenditure.
In 2011-2012, capital expenditure was $7.9 billion while recurrent expenditure, which includes expenditure
on mobile devices, consumables and wages, contributed to around 94.4% or $132.3 billion of the total
healthcare expenditure. Approximately $3.8 billion of the recurrent expenditure was spent on aids and
appliances, with growth of around 10% annually.3
Public healthcare services in Australia are provided by 753 hospitals, with 535 facilities having less than 50
beds, 136 facilities having 50 to 200 beds, and 82 facilities with more than 200 beds.
In 2011-2012, public hospitals accounted for the largest component (31.5%) of the recurrent healthcare
expenditure. Between 2007-2008 and 2011-2012, the recurrent healthcare expenditure on public hospital
services grew by almost 35%.4
Figure 2: Healthcare Expenditure by Area of Expenditure in Australia, 2011-12
Total Healthcare Expenditure

in 2011-2012
$ 140.2 billion
Capital Expenditure
$ 7.9 billion (5.6%)
Public Hospitals
$ 41.6 billion (31.5%)
Medical Services
$ 24.1 billion (18.2%)
Private Hospitals
$ 11.5 billion (8.7%)
Recurrent Expenditure
$ 132.3 billion (94.4%)
Medications
$ 19.7 billion (14.9%)
Dental Services
$ 8.5 billion (6.4%)
Aids & Appliances

$ 3.8 billion (2.9%)
Others
$ 23.1 billion (17.4%)
Note: Others include patient transport services, research, community health, public health, administration, etc. Source: AIHW
3
Australian Institute of Health and Welfare , Health Expenditure Australia 2011-12, http://www.aihw.gov.au/publicationdetail/?id=60129544658 (25 Sep 2013)
4
Australian Institute of Health and Welfare, Health Expenditure Australia 2011-12, http://www.aihw.gov.au/publicationdetail/?id=60129544658 (25 Sep 2013)
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V. THE COST OF INEFFICIENT MOBILE ASSET MANAGEMENT

Spending on public hospital services in Australia has increased by almost 2.5 times from $16.8 billion in
2001-2002 to $41.6 billion in 2011-2012.5 The cost of hospital care per casemix separation has been
escalating over the past two decades, mainly due to the advances in medical care and technology and
higher demand for health services with an ageing population and growing incidence of chronic diseases.
The cost of hospital care per casemix separation in public hospitals has increased from $4,215 in 20072008 to $5,204 in 2011-2012 at a compound annual growth rate (CAGR) of 5.4%.6
Figure 3: Cost Per Casemix-adjusted Separation in Public Hospitals in Australia, 2007-2008 to 2011-2012
Cost per
CasemixAdjusted
Separation
($)
5600
4,918
5,204
4,706
4,531
4400
4,215
3200
2000
2007 - 08
2008 - 09
2009 - 10
2010 - 11
2011 - 12
Source: AIHW
5
Australian Institute of Health and Welfare, Health Expenditure Australia 2011-12, http://www.aihw.gov.au/publicationdetail/?id=60129544658, http://www.aihw.gov.au/publication-detail/?id=6442467479 (25 Sep 2013)
6
Australian Institute of Health and Welfare, Hospital Performance: Cost per Casemix-adjusted Separation, http://www.aihw.gov.au/
haag11-12/hospital-performance-cost-per-separation (25 Sep 2013)
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Although Australia is ranked among the most efficient healthcare systems in the world,7 it can still reduce
its healthcare spending without compromising the quality of care. While factors such as medical errors,
hospital-acquired infections, treatment variations, ineffective use of information technology (IT), preventable
hospital admissions and readmissions can result in higher costs, under-utilisation of mobile assets also
contributes to hospital over-spending. It is estimated that $1 billion can be saved by having a better pricing
system for public hospital treatment in Australia.8 There is a huge gap between the treatment costs in highand low-cost hospitals with the funds being spent inefficiently in the hospitals that provide the same level
of care at a higher cost.
The total cost of mobile assets for public hospitals, which

includes expenditure on inventory, rental, and maintenance, is
estimated at around $250 million in 2013 and growing at almost
8% annually.9
For public hospitals, the total cost of inefficient mobile asset management is
estimated as:9

Around $32 million annually due to under-utilisation of mobile assets.
Approximately $16 million annually in inventory that needs to be replaced due

to either loss or mishandling of mobile assets.
Roughly $16 million annually in maintenance of over-purchased mobile assets.
As much as 32,500 hours of nursing time each day. Equivalent to $957,000 in

nursing staff salaries and a negative impact on patient care and satisfaction.
Bloomberg Visual Data, Bloomberg Best (and Worst): Most Efficient Health Care: Countries, http://www.bloomberg.com/visual-data/
best-and-worst/most-efficient-health-care-countries
8
Grattan Institute, Controlling Costly Care: A billion-dollar Hospital Opportunity, http://grattan.edu.au/
publications/reports/post/controlling-costly-care-a-billion-dollar-hospital-opportunity
9
Frost & Sullivan analysis based on data collected through interviews and published data. Average salary of nurses taken as
$29.45/hour based on nursing wage rates published by Queensland Heath.
10
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One of the more significant costs of inefficient mobile asset management is the amount of time spent by
nurses in locating mobile devices. With an estimated 65,000 nurses employed in public hospitals, and with
around 30 minutes on average lost each shift to find mobile assets, the daily loss is estimated at 32,500
hours in patient care, equivalent to around $957,000 per day in salaries.9
In 2011, all States and Territories agreed to a range of National Health Reforms by signing the National
Health Reform Agreement. One of the key provisions under the agreement was the adoption of activitybased funding (ABF) as the primary basis for funding the majority of public hospital services, with an aim
to improve timely access to quality care and maintain sustainability and efficiency of public health services.
With ABF, hospitals get paid for the number and mix of patients they treat. A facility receives more funding
if it treats more patients and complicated treatment cases. Thus, it is important for hospitals to be able to
accurately allocate costs and expenditure, including recurrent costs, based on the patient load.
9
Frost & Sullivan analysis based on data collected through interviews and published data. Average salary of nurses taken as
$29.45/hour based on nursing wage rates published by Queensland Heath.
11
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VI. CURRENT PROCESSES FOR MANAGING MOBILE ASSETS

Tracking hospital expenditure and allocating cost by service is a critical task for hospitals, as it directly affects
funding decisions and the allocation of resources. However, while capital expenditure is relatively easy to
plan and monitor, recurrent expenditure, particularly for hospital consumables and equipment costing below
a threshold value, is more difficult to measure and manage due to the lack of adequate and consistent
procedures to track these costs. Frost & Sullivan research, based on data from the Australian Institute of
Health and Welfare (AIHW), shows that recurrent expenditure has increased, on average, at 10% per annum
in public hospitals. Our study has indicated that the higher healthcare expenditure has been primarily due
to a general increase in prices of devices and consumables. Only one in 10 of the respondents interviewed
by Frost & Sullivan stated that recurrent healthcare expenditure had increased due to investments in more
sophisticated devices and technologies.
Figure 4: State of Current Asset Management Processes at Australian Public Hospitals
Ideal World
Real World
Point of Care
Point of Care
Dept. X
Dept. Y
Dept. X
- Timely
Return
- Delayed
Return
- Erroneous
Record
Equipment Keeping
Store
- Central or distributed
- Electronic Recording
Equipment of Entry and Exit
Store
- Timely
Return
- Timely
Maintenance
Maintenance
12
Dept. Y
Lost
Equipment
- Delayed
Return
- Reactive
Maintenance
Maintenance
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Even in an ideal situation, with existing asset management

practices and solutions, hospitals are unable to track movement
and usage of high-volume, low-to-medium value equipment in
real-time, allowing room for precious data and time to be lost
between processes.
According to interviews with biomedical engineers, investments in new technologies and infrastructure
are evaluated based on their impact on both delivery of care and hospital costs. The return on investment
(ROI) in terms on improvements in the quality and efficiency of care is becoming an increasingly important
management discussion, even in public hospitals. One out of three nursing unit managers reveals
that investments directly associated with better care delivery are generally given priority over other
infrastructural improvements.
Almost all respondents state that their hospitals maintain electronic inventories of mobile assets, but only
one reports the current use of a tracking system which notifies equipment managers when a mobile device
is moved between designated areas. At all the other hospitals surveyed, asset tracking is conducted through
register entries by staff. There are conflicting opinions surrounding the management of electronic inventories
half of the respondents prefer centrally-managed stores, while the other half are likely to delegate the task
to the respective departments. In this context, existing processes for mobile asset management can be
summarised as follows:
13
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Only a small number of hospitals are considering investing in real-time location sensing (RTLS) technologies
that allow automated, real-time asset tracking (see Table 3).
Table 2: Current Mobile Asset Management Practices in Public Hospitals

Current State of
Asset Management Systems
Proportion of Hospitals by Bed Size

<500 Beds
>500 Beds
Electronic asset management system only
30%
25%
Asset management and tracking system
0%
5%
No electronic system
25%
5%
Source: Frost & Sullivan research
There is an opportunity for improvement in the area of asset maintenance. Current asset management
systems do not support advanced analytics capabilities, or the ability to integrate with clinical information
systems and electronic health records (EHR).
Table 3: Proportion of Hospitals Considering an Electronic Asset Management and Tracking Solution
<500 Beds
>500 Beds
Considering an electronic asset management
and tracking solution
15%
20%
14
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VII. COSTS ASSOCIATED WITH MOBILE ASSET MANAGEMENT

As healthcare facilities strive to reduce costs and improve the quality of care, mobile asset management
becomes a highly-critical issue. The efficient management and tracking of mobile assets ensures the
availability of the right device to the right person at the right time and place, resulting in improved clinical
workflow and allowing the hospital staff to concentrate on patient care.
Key factors that impact mobile asset management include:

Level of utilisation of equipment;
Level of loss and misplaced equipment;
Equipment turnaround time;
Level of maintenance and cleaning of equipment; and
Level of inventory in relation to equipment.
Mapping mobile device demand and trends within hospitals is a complex function as it varies considerably
across departments. Acute and emergency care departments are device-intensive with a higher average
cost of devices per bed compared to sub-acute, general wards, and aged care units. The cost of mobile
devices has risen significantly at public healthcare facilities in Australia. While currency fluctuations have
contributed to price increases, another primary driver is market perception, where prices for healthcarerelated assets, even on standard purchases such as mattresses for hospital use, tend to be marked at a
premium price by vendors. Maintenance and replacement costs of mobile devices have escalated as well,
especially for the acute and emergency care units.
This Frost & Sullivan study has gathered data and opinions on the following areas:

Volume of mobile devices per bed;
Cost of mobile devices per bed;
Utilisation of mobile devices;
Cost of maintenance, repair and replacement of mobile devices; and
Capital expenditure and rental cost of mobile devices.
15
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Table 4: Average Number of Mobile Devices per Bed in Public Hospitals in Australia, 2013
Average number of
mobile devices per bed

<500 Beds
>500 Beds
<5
34%
38%
6-10
58%
38%
>10
8%
24%
Source: Frost & Sullivan research.

Note: Some of the respondents did not provide exact numbers on average number of mobile devices per bed.
Assumptions were made for these facilities based on their bed size.
As shown in Table 4, most public hospitals have less than 10 mobile devices per bed. Approximately 90%
of hospitals with less than 500 beds and 75% of hospitals with more than 500 beds have less than 10
mobile devices per bed. The average number of mobile devices per bed is slightly higher at larger hospitals
(more than 500 beds).
Around 70% of hospitals have seen an increase in the

average number of mobile devices per bed in their facilities
in the past three years. While this growth, driven by the
introduction of advanced technologies, focuses on improved
patient monitoring and new treatment options, it also increases
many complexities for hospital personnel. Without proper
asset management, staff are forced to either spend more
time locating equipment, or maintaining quality care. This can
potentially drive procurement costs up as there is a critical need
for devices to be readily available when required.
16
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Table 5: Average Cost of Mobile Devices per Bed11 in Public Hospitals in Australia, 2013
Average cost of
mobile devices per bed ($)

<500 Beds
>500 Beds
<2,000
25%
12%
2,000-4,000
67%
50%
>4,000
8%
38%

Note: Some of the respondents did not provide exact numbers on average cost of mobile devices per bed.
As shown in Table 5, the average cost of mobile devices is around $3,080 per bed in public hospitals, but
the cost is higher in hospitals with more than 500 beds ($3,500 per bed) compared to hospitals with fewer
than 500 beds ($2,670).
The average cost of mobile devices per bed is increasing

at approximately 8% annually, with more than 90% of
hospitals saying they have seen an increase at their facilities
in the past three years. As a result, hospitals are spending a
significant amount of funds on mobile assets. Lack of attention
in improving the management and usage of these devices also
escalate the associated costs.
Respondents were provided a list of mobile assets that could be used in their facility. We obtained an estimate of the number of
devices attached to an occupied patient bed in a general ward followed by the respondents estimate on the average cost of these
devices attached to the bed. The average cost does not include cost of maintenance or loss of mobile assets.
11
17
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Table 6: Utilisation of Mobile Devices in Public Hospitals in Australia, 2013

Utilisation of
mobile devices

<500 Beds
>500 Beds
<40%
18%
0%
40%-60%
40%
50%
>60%
42%
50%

Note: Some of the respondents did not provide exact numbers on utilisation of mobile devices.
In an ideal scenario, utilisation of mobile assets should be more than 80%, with units like emergency care
running at over 90% utilisation.12 However, as shown in Table 6, our research indicates that in 50% of
hospitals with up to 500 beds, the utilisation of mobile devices is less than 60%. Although, the utilisation of
mobile devices is slightly higher for larger hospitals (more than 500 beds), it is nowhere near the optimum
level. Under-utilisation has significant cost implications as it leads to over-purchasing of assets, increased
asset loss, and reduced staff productivity due to misplaced devices.
Based on Frost & Sullivan research, the total value of mobile devices
at a typical 500-bed public hospital is estimated at $1.8 million. In a
best-case scenario the hospital is using devices at 60% utilisation,
whereas the latest Real-time Location System (RTLS) systems
have shown that utilisation of up to 80% can be achieved. Thus, a
500-bed hospital that carries mobile assets worth $1.8 million
can expect to reduce just its purchasing cost of inventory by
$360,000 annually through advanced asset management and
tracking solutions. This does not include the benefits provided in
reducing maintenance and staffing costs.
Interviews conducted by Frost &Sullivan, GE Healthcare, Out of Control: Little-used Clinical Assets are Draining Healthcare Budgets,
http://partners.gehealthcare.com/07_HFM_July_horblyuk.pdf (Jul 2012)
12
18
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Figure 5: Trends in the Volume, Cost, and Utilisation of Mobile Devices in Public Hospitals in Australia, 2010-2013
Proportion
of Respondents
100%
23%
8%
20%
6%
18%
54%
54%
50%
35%
18%
0%
Number of mobile
devices per bed
13%
38%
13%
Average cost of mobile
devices per bed
Increase (>20%)
Increase (10-20%)
Increase (<10%)
Decrease (>20%)
Decrease (10-20%)
Decrease (<10%)
Average utilisation
of mobile devices
No Change
Source: Frost & Sullivan analysis based on data collected through interviews.
As shown in Figure 5, around 50% of hospitals are seeing an increase of over 10% in the number of mobile
devices per bed and at around one-third of hospitals the cost of mobile devices per bed is increasing by
over 10%.
In 2009, NSW Health invested $70 million in 10,000 new state-of-the-art infusion
pumps to improve the safety of IV medication delivery in the States public healthcare
facilities. If the State health department had performed a thorough assessment
of metrics using an asset management and tracking solution to evaluate the actual
demand for pumps, pump utilisation, pump delivery time to understand the number of
pumps it had at hand, how the pumps were being used by staff, and actual purchase
need, it could have saved around $14 million in capital expenditure and additional
operating costs for maintenance and service per year by increasing pump utilisation by
only 20%.13
Source: NSW Health, NSW: Hospitals Get $70 Million Injection For IV Pumps, http://ehln.org/?p=382 (10 Sep 2009) and Frost &
Sullivan analysis
13
19
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Table 7: Average Annual Cost and Trend in Capital Expenditure, Rental Cost, Replacement Cost, and Maintenance Cost
of Mobile Devices for a Typical 200 Bed Public Hospital in Australia, 2010-2013
Average Cost $ (2013)
Rental cost of mobile devices
$35,000
Replacement cost due to mishandling or loss of mobile devices
$53,000
Maintenance cost of mobile devices
$280,000
1-4%
annual growth
5-8%
annual growth
Trend (2010-2013)
>8%
annual growth
Public hospitals have witnessed an increase in rental, replacement, and maintenance fees of mobile devices
over the past three years (see Table 7).
Most hospitals prefer to buy rather than rent mobile devices, excluding oxygen cylinders, specialty beds,
mattresses, and wheelchairs, to avoid potential delays that often occur when rental companies are unable to
deliver products on time. Additionally, a number of hospitals complain about the inconsistency in the quality
and condition of devices supplied. The higher emphasis on buying and storage leads to unpredictability in
the investment required for purchasing mobile devices each year.
Approximately 10% of the asset inventory needs to be replaced annually, due to either loss or mishandling
of devices. A typical 500-bed public hospital is estimated to spend an average of $175,000 per year on
replacing mobile devices and an average of $700,000 on maintenance of existing mobile devices every year.
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Top 3 Myths Regarding Mobile Asset Management

A High Level of Asset Utilisation is a Positive Performance Indicator

Around 50% of respondents state that their hospitals have mobile asset utilisation
over 60%, with three reporting above 90% utilisation. However, these estimates
are largely based on a shortage of functional devices at the respective hospitals
and staff having to manage with the limited devices available. Even with 90%
utilisation rate, hospitals still report the inability to find devices when needed, as
well as a large part of inventory requiring maintenance and repairs. Respondents
state that often device utilisation is high because there is low availability. Therefore,
asset utilisation alone is not a reliable indicator of hospital efficiency.
Misplacement of Mobile Assets Do Not Impact Patients

Mobile devices tend to move around a healthcare facility according to patient
needs. Fixing devices and restricting their mobility through rules and policies
limits patient mobility, and has a substantial impact on the patient experience.
Moreover, nurse unit managers report delays in patient admission and start times
of IV therapies and other procedures because they are unable to access the right
equipment in a timely manner.
Technology is the Solution to All Problems

Employees at healthcare facilities seek technological solutions to address
challenges in asset management. However, few seldom take into consideration
the existing processes and workflows at their facilities. Technology deployment
without a rigorous analysis of current workflows is not likely to create a significant
improvement. Instead it could lead to further obstacles and inefficiencies in the
long run as the very workflows which act as a foundation to the technology would
be unproductive.
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The cost associated with inefficient mobile asset management in hospitals is significant as it can lead to
devices being misplaced or lost, equipment requiring frequent repairs or replacement, and clinical staff
spending considerable amount of time locating equipment, which increases investment in assets, escalates
hospital expenditure, and affects the quality of healthcare services.
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VIII. OTHER COSTS ASSOCIATED WITH INEFFICIENT MOBILE ASSET MANAGEMENT

The financial impact of inefficient asset management is only half the story. Ineffective mobile asset
management is an essential source of frustration for hospital staff, including for example, nurses who
interact with patients and use the devices, and equipment managers responsible for management and
maintenance of the devices.
Our study has identified the following issues related to inefficient mobile asset management:

Inability to locate mobile devices when needed;
Time lost locating mobile devices;
Challenges in working with multiple vendors for renting mobile devices; and
Mishandling or loss of mobile devices.
Figure 6: Frequency of the Inability to Locate Mobile Devices When Needed

Proportion
of Respondents
100%
Average rating = 4.0

5
40%
Frequently
4
3
50%
25%
25%
0%
2
1
Never
10%
Inability to locate mobile
devices when needed
Note: Respondents were asked to rate the statement Inability to locate mobile devices when needed
on a scale of 1 to 5 where 1 stands for Never and 5 stands for Frequently.
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As shown in Figure 6, the hospitals surveyed agree that they are sometimes unable to find devices when
needed, with 65% of hospitals reporting that they face this challenge frequently at their facilities.
Around 95% of end users believe that the inability
to locate medical devices when needed affects
the quality of healthcare delivery, as it leads to
delayed patient treatment. Searching for missing
devices also places more pressure on the nurses
who are responsible for delivering timely patient
care. It significantly adds to their physical effort and
sneaker time during the course of the day.
This morning we had

to discharge an older
person and we needed a
wheelchair, and you can
never find one when you
need it so her discharge
had to be delayed.
Lost or misplaced devices are also a concern for equipment managers and biomedical engineers, because
timely delivery of appropriate devices is a key performance indicator for them. Some respondents describe
weekly search procedures which require a nurse to spend several hours in a week to collect devices that are
not in the correct location and return them to their appropriate stores. There is opportunity for automation
here that will allow biomedical engineers to capture 100% of performance quality and calibration checks
while eliminating the need for human resources and reducing the chance of error or oversight.
Table 8: Number of Minutes a Nurse Loses per Day in Locating Mobile Devices in Public Hospitals in Australia
Average number of minutes a nurse loses per day
in locating mobile devices
Proportion of nurses
Less than 15 minutes
17%
15-30 minutes
32%
31-45 minutes
9%
Greater than 45 minutes
42%
Source: Frost & Sullivan research.
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As shown in Table 8, nurses on average
Sometimes nurses spend up to

an hour a day (locating mobile
assets). It impacts the quality
of service because when they
are looking for devices they are
not getting their patient care
work done.
spend about half an hour per day

locating mobile devices, with over 40%
of nurses saying they spend more than
45 minutes on this activity. Respondents
believe that nurses have to give up
time with patients for this activity,
which hinders the provision of efficient
patient care.
The Royal Adelaide Hospital campuses have over 2,000 nurses. Each nurse
spends an average of 30 minutes per day locating mobile devices. This
is equivalent to around 125 nurses in the campuses spending their entire
day on this activity and not being able to devote any time for patient care. 14
One respondent mentioned that they were able to overcome this issue of locating mobile equipment at their
facility after investing in an asset tracking and RFID system, which led to faster equipment turnaround time
and better utilisation of equipment.
Source: Royal Adelaide Hospital, http://www.rah.sa.gov.au/nurse/n_e_overview.php and Frost & Sullivan analysis based on data
gathered through the study.
14
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Figure 7: Challenges in Working with Multiple Vendors for Renting Mobile Devices
Proportion
of Respondents
100%

13%
20%
Major Challenge
3
50%
40%
2
1
Not a Challenge
27%
0%
Challenges in Working
with Multiple Vendors for
Renting Mobile Devices
Note: Respondents were asked to rate the statement Working with multiple vendors for renting mobile devices
on a scale of 1 to 5 where 1 stands for Not a challenge and 5 stands for Major challenge.
As shown in Figure 7, working with multiple vendors for the

rental of mobile equipment is not considered to have a big
impact on operational workflow, with only 13% of respondents
considering it as a major challenge. However, respondents
have raised particular issues in dealing with multiple vendors.
These include the impact on staff productivity as they need
to determine whether the products are of suitable quality,
conduct rigorous product comparisons from different
vendors prior to procurement to prevent delivery delays or
substandard quality, and organise timely delivery.
26
Staff spend more

time dealing with
vendors, chasing
up orders, and
generally doing
things they really
don't need to
be doing.
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Figure 8: Occurrence of Mishandling or Loss of Mobile Devices

Proportion
of Respondents
100%

25%
Frequently
4
25%
50%
3
2
31%
Never
19%
0%
Occurrence of
mishandling or loss of
mobile devices
Note: Respondents were asked to rate the statement Mishandling or loss of mobile devices
on a scale of 1 to 5 where 1 stands for Never occurs and 5 stands for Frequently occurs.
As highlighted in Figure 8, all respondents experience

mishandling or loss of mobile devices, with half reporting that
this occurs frequently at their facility. Some respondents were
able to quantify the cost impacts, including an estimated
$225,000 annually (570-bed hospital), $100,000 annually
(400-bed hospital), $60,000 (370-bed hospital), $50,000
(250-bed hospital), and $24,000 (200-bed hospital) due to
mishandling or loss of mobile devices. Other respondents
Six
years
ago, I had 80
wheelchairs. I am
down to about
15 simply due to
the loss of these
wheelchairs.
gave additional quantifiable results such as:

Replacement of 50% of wheelchairs in the past 18 months;
Replacement of 10% of equipment every year;
Impact on patient care due to loss of vital signs monitors;
Loss of IV pumps as they are moved around between wards; and
Loss of around 15 out of 70 wheelchairs purchased two years ago.
27
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Device maintenance is conducted based on defined timelines and procedures. Current systems are neither
predictive in terms of required maintenance schedules or costs, nor are they able to detect or diagnose
ad-hoc maintenance and repair needs. A few respondents describe incidents where mobile devices were
found left at inappropriate locations. It is difficult for biomedical engineers to locate abandoned devices and
spend additional time and money to repair them. Repairs can take up to six months and the hospital has
to bear the opportunity cost of not having the device readily available.
Public hospitals have severe space constraints which can make device storage difficult. Many hospitals cite
this as a major reason for being unable to create a central store for all equipment. Creating a central storage
location requires significant space, and adds to the staffs time and effort to retrieve the devices. Hospitals
generally maintain their own inventories each department is responsible for the maintenance, safety, and
storage of its pool of devices. However, this does not prevent devices from moving around departments
without the original owner being informed, leading to conditions that further increase device search times
as well as create an atmosphere where co-workers compete for resources.
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IX. THE PATIENT EXPERIENCE IS IMPACTED

The impact of ineffective asset
management on patients
and the quality of care has
emerged as a critical issue
in our research. While most
hospital decision-makers
state that gaps in hospital
asset management did not
affect patient care at their
Inability to locate devices impacts

patients because there is a lag between
the expected and actual service time.
It makes patients and their families
nervous and sometimes becomes a
hurdle in procedures as well. Overall, it
leaves a bad impression of an understaffed, poorly-managed hospital.
facility, 90% of nursing staff

respondents agreed that patients do feel the impact. Furthermore, around 25% of respondents report
delays in admissions, treatment start times or discharges due to lack of immediate availability of mobile
devices, such as IV pumps and wheelchairs. In some conditions, procedures are delayed and affect the
quality of care and prognosis, which is noticed by patients and care givers.
Sometimes it can become a life and death situation especially

with certain devices that are hard to locate.
Some respondents have provided specific examples of how inefficient asset management can affect the
quality of patient care:

Delays in discharging patients due to the inability to find a wheelchair;
Slow to start IV therapy for a patient as staff unable to find the necessary equipment;
Inability to shift patients from accident & emergency (A&E) department to the general ward due to
unavailability of a telemetry system; and
Constant calls from the recovery ward as they are short of patient-controlled analgesia
(PCA) pumps.
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With the adoption of ABF as the primary basis for funding a majority of hospital services, public hospitals
are being encouraged to maximise the delivery of services with available funds and prevent delays in
providing clinical care. There is also a push to introduce pay-for-performance schemes payment models
that reward physicians, hospitals, medical groups, and other healthcare providers based on performance
measures for quality and efficiency. Queensland Health is the first to incorporate pay-for-performance
elements into hospital funding in Australia through their Clinical Practice Improvement Payment (CPIP) trial
program, where hospitals are paid to achieve targeted levels of patient safety and quality.15
The Commonwealth and State and Territory governments have agreed to improve patient access to elective
surgery, emergency department, and sub-acute services under the National Health Reform Agreement.
The National Emergency Access Target (NEAT) is a component of the agreement with an aim to ensure that
by 2015, 90% of all patients presented to a public hospital emergency department (ED) will either physically
leave the ED for admission to hospital, be referred to another hospital for treatment or be discharged
home within four hours. The National Elective Surgery Targets (NEST) is another component with the aim
to progressively increase the timeliness of elective surgeries performed so that by 2016, 100% of patients
receive their elective surgery within the clinically-recommended time.16
Healthcare facilities must commit to improving workflow efficiency, patient throughput, staff productivity as
well as patient and staff safety to implement these initiatives and programs. Improvements in management
of mobile assets will be a critical component in ensuring that patients receive appropriate medical care at
the right time, and that nursing staff spend their time on patient care, which is their principal responsibility,
rather than locating mobile assets.
Queensland Health, Patient Safety and Quality Plan 2008-2012, http://www.health.qld.gov.au/psq/governance/

docs/s&q_patient_plan_v4.pdf
New South Wales Health, National Elective Surgery Targets, http://www.health.nsw.gov.au/Performance/Pages/NEST.aspx
15
16
30
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X. ADOPTION OF MOBILE ASSET MANAGEMENT SOLUTIONS

As hospitals adopt more healthcare IT solutions to enhance quality, safety, and efficiency, implementation of
mobile asset tracking and management solutions becomes a crucial requirement to overcome the challenge
of improving quality of care while lowering costs.
In late 2013, South Australia Health went to market with a tender inviting suppliers to submit responses for
a state wide clinical asset solution. The primary objective of the South Australian Biomedical Engineering
(SA BME) directorate of SA Health, Infrastructure is to assure the safety, effectiveness, availability and
compliance of biomedical technology used directly for patient diagnosis, treatment or monitoring for or in
connection with the public hospital and healthcare facilities of SA Health.17
While all respondents agree that there are inefficiencies in the current asset management practices at their
facilities, a majority do not have a robust functional system that can overcome the impact of inefficient
mobile asset management (see Figure 9).
Figure 9: Current Usage of an Asset Management and Tracking Solution in Public Hospitals in Australia, 2013
Proportion
of Respondents
100%
Yes
No
60%
83%
50%
40%
17%
0%
200-500 beds
>500 beds
17
NSW Health, Annual Report 2012-2013, http://www.health.nsw.gov.au/publications/Publications/annualreport13/HealthAR-201213-ch06-Funding-and-Expenditure.pdf
31
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As shown in Figure 9, although a majority of
The solution is essentially

an inventory of assets
that links back to various
cost centres. It does
not provide any usage
or analytics or even
updated information on
maintenance. It does
not include tracking as
well. It is more a postevent log rather than a
predictive solution.
respondents, especially in hospitals with fewer than

500 beds, have an asset management solution in
their facility, these systems are not comprehensive
and do not cover all the aspects of a complete
asset management and tracking solution. With
the exception of one respondent, all the facilities
surveyed have solutions that do not have real-time
tracking capabilities for mobile equipment. Most
of the systems installed at these facilities do not
perform any analytics, lack predictive capabilities,
and are not integrated with the hospitals core
IT system.
Although a majority of respondents express a desire

to have a comprehensive mobile asset tracking and
management solution implemented at their facility,
the acquisition cost is a key barrier to the adoption
of the system. Other barriers include:

Uncertainty about the potential benefits against

the high cost of implementing the system;
Lack of funding or budget constraints;
The belief that only private hospitals are able to

adopt such a solution as they can pass on the
cost to patients;
Change management issues related to the

implementation of such a system as it demands
major operational changes; and
32
Lack of initiative from the hospital management.
We are looking for a realtime GPS tracking for

both equipment and staff.
My ideal system would
look like something with
GPS tags or wireless
system throughout the
organisation. Aligned
with that should be a
software program with
a live view and printing
capabilities.
www.frost.com
The cost of the technology to have a system is high. The benefit

versus the cost does not really stand out at the moment so I
doubt if I would consider investing in a tracking solution. I can't
see a lot of benefit in it unless you are a private hospital.
I don't know why the management has not thought about this.
Maybe it is the cost or just something that has never been
brought up either internally or externally.
In order to improve the adoption of mobile asset tracking and management solutions, there is an immediate
need to increase the awareness of the benefits of these solutions among hospital stakeholders and decisionmakers, in areas such as:

ROI achieved through cost savings (capital and operating expenditure) even if the initial outlay
is high;
Benefits such as improved patient care, staff productivity, and workflow efficiency; and
Processes in place to assist the hospital staff to adapt to operational changes.
33
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XI. SYSTEMS AND PROCESSES TO CUT THROUGH THE CLUTTER

An essential process missing in technology implementations today is the mapping of hospital workflows.
Few hospitals have conducted an analysis of their existing business structure and associated workflows to
ensure that their operations are in line with their business goals. Frost & Sullivan research has found that
cost centres and hospital workflows are often not in line with actual revenue-generating activities, resulting
in significant inefficiencies in managing resources that are shared across cost centres.
Once, hospital workflows have been streamlined, a best practice is to design automation systems that
overlay the workflow blueprint. The goals of automation should be to:

Reduce human intervention and the chances of human error;
Capture as much data in the shortest time possible;
Reduce costs; and
Improve the comfort for both end-users and patients.
Advanced Solutions to Improve Asset Management

AgileTrac Asset Manager from GE Healthcare
The AgileTrac Asset Manager provides hospitals with the technology and workflow solutions to break the
cycle of mismanagement and underutilisation of mobile assets such as IV pumps, monitors, and wheelchairs.
This facilitates much-needed gains in achieving patient care, staff productivity, and cost management goals.
34
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Using the RTLS technology, AgileTrac enables the tracking of mobile medical assets via easy-to-use web
tools. Users get direct access to the information they need to:

Locate equipment quickly;
Control distribution by using real-time inventory tracking to manage stock levels of critical assets;
Improve compliance and safety by tracking device lifecycles, generating reports on the percentage
of time in use, storage, cleaning, and repair;
Reduce rental expenses by calculating rental cost per day and tracking due dates for timely return
to avoid excess fees;
Decrease capital expenditures by right-sizing the equipment inventory and preventing impulse
buys; and
Prevent loss through customised loss prevention alerts that help keep vital equipment where it
belongs.
Here are examples of how hospitals are improving efficiency and reducing costs with the AgileTrac
Asset Manager.

One hospital had two pumps for every patient. With more efficient workflow processes, they
were able to take 250 pumps out of the mobile equipment inventory. Capital expenditure fell by
US$450,000 and operational expenses by US$30,000 per year.
By redesigning asset workflows and implementing AgileTrac, one hospital reduced its pump
inventory by one-third, resulting in maintenance savings of US$104,000 per year. It also eliminated
730,000 minutes of pump search time the equivalent of 7.5 FTEs.
A 350-bed hospital was able to cut pump inventory by 20% for lease/rental savings of US$1
million and virtually eliminate equipment-related delays in patient care with AgileTrac.
A health system uses AgileTrac to manage more than 11,000 assets from wheelchairs to IV pumps
in four hospitals. Within five years, the system has saved more than US$5 million by reducing
inventory and improving asset utilisation and staff productivity.
Please visit the following website for additional information on GE Healthcares asset
management solutions:
http://www3.gehealthcare.com.sg/en-GB/Services/Comprehensive_Services/Asset_Management
35
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Case studies on how asset management solutions from GE Healthcare

have benefitted hospitals
Case Study 1
Client:
Ellis Medicine, a 438-bed community and teaching healthcare system serves as the principal healthcare
provider for more than 800,000 people in upstate New York.
Challenge:
In 2010, Ellis Medicine was considering upgrading its analog infusion pumps to newer-generation smart
pumps that improve the safety of IV medication delivery. At the time, Ellis had approximately 500 pumps
at its main hospital, but nurses continually complained that it was difficult to find one when needed. The
facility wanted to understand what it had on hand, how staff were using the pumps, and what it really
needed to purchase.
Solution:
Ellis Medicine engaged GE Healthcare to find the answers to its questions. Initial analysis revealed that the
hospital had more than enough pumps, but ineffective workflow and pump management processes were
hampering distribution and causing perceived shortages. Working with GE, Ellis staff determined a desired
future state of operations and developed a procedure to better manage IV pumps. Central to that solution
was the AgileTrac real-time location system, where an RFID tag is placed on a piece of equipment so its
location can be tracked in real-time on computers throughout the facility. Ellis has expanded its mobile
asset tracking to include other pieces of equipment such as telemetry units and wound vacs.
Benefits:
Improved mobile asset management has had a significant operational impact for Ellis Medicine:

Reduced inventory expenses: Although there were 500 IV pumps in circulation, Ellis Medicine
discovered it only required around 340 to meet patient needs efficiently, which helped in reducing
both capital and operating costs for maintenance and service.

Avoidance of capital expenditure: In purchasing next-generation IV pumps, Ellis was able to reduce
its projected capital outlay by 30%.

Lower rental costs: With more effective distribution and tracking of mobile assets, Ellis now leases
fewer pieces of equipment.

Improved biomed efficiency: One unforeseen benefit was the ability to quickly locate critical pieces of
equipment to fulfil regulatory inspections.
The reductions in capital and operating expenditures have generated more than US$1.1 million in savings
and cost avoidance for Ellis Medicine since 2010, more than twice the financial return guaranteed by GE
Healthcare.
36
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Case Study 2
Client:
Virtua, a healthcare system in New Jersey consists of four hospitals, 885 beds, and several additional
facilities including two urgent-care centers.
Challenge:
In 2010, Virtua was preparing to open a new replacement hospital in New Jersey. At the time, in order
to locate one of Virtuas 10,000 mobile medical devices, staffers often had to hunt through hallways and
make multiple phone calls.
Solution:
Virtua embarked on an initiative of deploying GE Healthcare's AgileTrac solution to better monitor and
assign beds, as well as the IV pumps, telemetry units, and other mobile medical equipment nurses and
doctors rely on to care for patients. Each piece of equipment was tagged with an RFID tag that enabled
managers to track assets throughout the hospital on the computer, making it easier and quicker to find
needed equipment.
Benefits:
Virtua cut equipment wait times saving an estimated US$1.2 million after installing the solution. Improved
mobile asset management has provided significant operational impact for Virtua:

Prior to implementing the system, the average wait time between asking for an urgently-required
piece of equipment and receiving it was 202 minutes. The average wait time is now 12 minutes an
improvement of 94%;

For routine equipment, which are not urgently needed, response time improved by 92%, or from an
average of 184 minutes to 14 minutes; and

In the case of frequently used, high-demand equipment, such as IV pumps, AgileTrac alerts the
equipment depot when inventories are low so that supply can be replenished before requests are
made.
37
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XII. APPENDIX
Contact:
David Dembo
David Venning
GM Solutions
Asset management product leader
GE Healthcare ANZ
GE Healthcare ANZ
03 9239 8493
03 9239 8482
0410 649 789
0417 247713
david.dembo@ge.com
david.venning@ge.com
Rhenu Bhuller
Maz Khan
Natasha Gulati
Senior Vice President,
Industry Director,
Industry Manager,
Healthcare
Healthcare
Connected Health
Asia-Pacific
Australia & New Zealand
Asia-Pacific
P: +65 6890 0986
P: +61 2 8247 8908
P: +603 6204 5876
E: rbhuller@frost.com
E: maz.khan@frost.com
E: natasha.gulati@frost.com
38
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Frost & Sullivan research services are for customers internal use and not for general publication or disclosure
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& Sullivan. No part of it may be circulated, quoted, copied or otherwise reproduced without the written approval of Frost & Sullivan.
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Reduce Your Cost Whilst Improving Patient Care &

Satisfaction: Inefficient Use of Mobile Assets is Costing

A Frost & Sullivan White Paper

Reduce your costs whilst improving patient care and satisfaction

Reduce your costs whilst improving patient care and satisfaction

Public hospitals in Australia spend as much

Table 1: Impact of Inefficient Mobile Asset

Daily loss in patient

$16 million per year

$16 million per year

$32 million per year

patient care process. Many of these devices

Reduce your costs whilst improving patient care and satisfaction

Frost & Sullivan research has identified that:

With the mounting cost pressures on healthcare

The average number of mobile devices used

delivery in Australia, wastage resulting from inefficient

in hospitals (currently about eight per bed in

mobile asset management is an unacceptable

general wards) is increasing every year;

cost burden on the public healthcare system.

The average total value of mobile devices in use

Many hospitals have not defined adequate

wards) is escalating every year;

processes and workflows that align their services

The average utilisation of mobile assets is 50%

with device usage. Few hospitals have identified

to 60%, far below the optimum level hospitals

the resources that can potentially be shared across

can potentially achieve;

cost centres to help reduce inventory. Likewise,

Hospital staff are often unable to locate mobile

few deploy technology systems on top of their

assets when needed;

business processes that provide real-time tracking

Nurses spend an average of about half an

of mobile devices, to enable time- and cost-

hour per shift to locate mobile assets, which

efficient collaboration and resource-sharing across

impacts patient care; and

Around 10% of mobile assets need to be

While there is growing awareness of the impact

of under-utilisation of mobile assets on costs,

Frost & Sullivan estimates that public hospitals

such as budget constraints and uncertainty about

in Australia are wasting more than $60 million

the potential benefits of asset management and

per year as a result of inefficient management

tracking solutions restrict their adoption.

of mobile assets. In addition, approximately

Reduce your costs whilst improving patient care and satisfaction

II. ABOUT THIS WHITE PAPER

This white paper is based on 20 discussions and

has been used to understand the spending

one forum with representatives from Australian

trends across Australian public hospitals, and

public hospitals to obtain their views on asset

the effect of mobile assets on overall costs.

management practices at their facilities. In order to

Frost & Sullivan has assessed the asset management

ensure fair representation from relevant stakeholder

and tracking solutions currently being used to arrive

groups, discussions were conducted with end users,

at an objective opinion on the level of market and