By Matt Skoufalos
Medical imaging equipment replacement planning is one of the most demanding responsibilities in healthcare technology management (HTM). The vocation already requires deep professional capabilities just to keep sprawling device inventories running. From mitigating downtime and hardening operations against security vulnerabilities, to establishing new lines of service and retiring old equipment, the work of keeping things running efficiently requires strategically navigating a number of competing priorities. When it comes time to replace a piece of imaging equipment that’s reached the end of its useful life, the way to most seamlessly manage that transition involves clear management oversight, a robust capital plan and an awareness of potential pitfalls along the way.
Clinical engineer Carol Davis-Smith, president of the Arizona-based Carol Davis-Smith & Associates LLC, said that most health systems anticipate their medical equipment replacement on a three- to five-year trendline that considers asset depreciation and availability of capital at its foundation.
“There never has been, nor will there ever be, enough financial resources to meet every need,” Davis-Smith said. “The trick is to understand the risk associated with what is ‘left on the table’ once the needs are prioritized.”
Defining End-of-Life: Technical, Clinical and Financial
Davis-Smith recommends a holistic forecasting approach to imaging equipment replacement that characterizes the device end-of-life in terms of technical, clinical and financial criteria. Technical end-of-life can be defined by the discontinuation of original equipment manufacturer (OEM) support for a device; financial end-of-life can be described by how much an asset has depreciated in value since its original purchase. She regards clinical end-of-life as the most complicated to define without a comprehensive understanding of the capacity of a device to achieve standards of care defined by clinical professional societies.
“The process is more about assessment and interpretation of several calculations rather than a single number,” Davis-Smith said.
“An asset may be considered ‘best-of-breed,’ but it has high maintenance issues (i.e., failures) that cannot be adequately addressed by the OEM and/or the HTM department,” she said. “This could be defined as technical end-of-life even though the product is manufactured, sold and supported by the OEM.”
“Another asset might be easily maintained and not depreciated, but it no longer meets the clinical standards of care,” Davis-Smith said. “This could be defined as clinical end-of-life.”
Then there’s medical imaging equipment, the longevity of which she describes as “serial-number-dependent” upon firmware and software availability. If hardware can’t be upgraded to a version capable of running the latest application software, or if it was manufactured with components that are no longer available, its clinical and technical viability might be challenged, even if it’s still largely functional.
“The longevity of the physical asset and the imaging application is heavily dependent upon the clinical standards of care,” Davis-Smith said, “[and] standards of care evolve with advances in academic and clinical research. It’s more about awareness and interpretation than mere calculations.”
Why a Longer Forecast Horizon Delivers Control
In addition to having a strong command of established inventory, ProHealth Care HTM Program Manager Lani Bartkowiak, in Waukesha, Wisconsin, said that capital spending for replacing medical imaging equipment should follow a thorough understanding of replacement needs. Her organization began operating with a five-year financial forecast that subsequently evolved into a seven-year trend analysis to deliver greater control.
“It provides the C-Suite a line of sight into what the financial ask will be over the next few years,” Bartkowiak said. “It allows them to start thinking about how they are going to juggle the competing priorities of the organization while ensuring we continue to provide excellent patient care and safety.”
“To a certain extent, having a plan can be a staff-satisfier,” she added. “Technologists who work at multiple health organizations are exposed to different equipment, and it can be a satisfier to know we’re invested in the technology they’re going to be using every day.”
Establishing an equipment replacement plan and the financial need that underpins it can also lead to unexpected opportunities for expedited purchases. Bartkowiak described scenarios in which HTM directors have advanced future capital spending because their institutional financial health incentivized doing so. Only those leaders whose forecasting has been prepared on a long enough trendline are able to take advantage of such opportunities.
“By laying out those replacement plan needs, I am able to support the additional ask and move on things sooner,” she said.
When Operational Needs Drive Equipment Replacement
Sometimes equipment replacement is prioritized based on operational needs; for example, opening a new brick-and-mortar, establishing a new line of service, or an institutional merger or acquisition. Contemplating the impact of an equipment purchase or retirement on all its users within an organization can lend greater weight to a decision as priorities take shape. So, too, does the institutional capacity to service and maintain it, particularly given the expense of an imaging modality.
“We invest substantially in training our technicians. In most modalities we have primary and secondary support and, in some modalities, tertiary support,” Bartkowiak said. “Some organizations may not be financially positioned to invest as much in training.”
“It all comes down to what is the organizational risk tolerance and where they’re comfortable spending their money,” she said.
Who Makes the Call: The Capital Decision-Making Team
When decisions are being made about how to manage capital expenditures around imaging equipment replacement, most large health systems tap a similar roster of decision-makers, said Jason Theadore, vice president of radiology operations for AdventHealth Florida Specialty Network and chief operating officer of Ambulatory Services for AdventHealth Central Florida Division.
Capital strategy is overseen by the chief financial officer (CFO), whose department manages a variety of acquisition options, including cash purchases, capital or operating leases, and managed-equipment-service or equipment-as-a-service arrangements, Theadore said.
Beyond those responsibilities, chief medical officers (CMO) and chief clinical officers (CCO) “speak to clinical necessity and strategy,” he continued, as do imaging and radiology service-line leaders and relevant physician chairs affected by an equipment purchase.
“HTM and clinical engineering [personnel] supply objective condition and cost data; supply chain [professionals] and the value-analysis committee handle sourcing, group-purchasing leverage and standardization,” Theadore said. “Facilities and construction enter the picture whenever a replacement triggers a room build-out, and IT and cybersecurity have effectively become permanent members [of capital acquisition teams], because every modern imaging device is a networked endpoint that must integrate with PACS and survive a security review.”
“In a large, geographically distributed system, this typically operates at two levels: facility or regional capital councils feeding a system-level committee that allocates a pooled capital budget across the enterprise,” he said.
Even given the complexity and resiliency of such an expert-heavy professional planning structure, the forecasters don’t always hit their marks. Theadore said that the chief hurdle that their projections must clear is the quality of the data that informs them.
In 2025, the American Society for Healthcare Engineering (ASHE), which produces industry-wide capital-planning benchmark studies, found that “a large share of hospital capital is allocated on age estimates and anecdote[al evidence] rather than performance data,” Theadore noted.
The Data Problem at the Heart of Forecasting
“Roughly two-thirds of healthcare CFOs report limited or no visibility into actual maintenance-cost history and real-time asset condition when annual budgets are assembled. The countermeasure is a disciplined CMMS (computerized maintenance management system) serving as the single source of truth, normalized device nomenclature and active data governance, which is unglamorous and the highest-leverage step available to most systems.”
Unplanned equipment failures present another obstacle to achieving accurate capital forecasting, which Theadore described as “the mid-year emergency replacement that detonates the plan and forces a premium purchase with no negotiating leverage.”
“Planners account for it with contingency reserves, criticality scoring that identifies the assets that cannot be allowed to fail, planned redundancy for the most critical modalities, and condition-based and predictive maintenance that converts surprises into scheduled events,” he said.
Likewise, technologies that deliver more than an iterative leap in significance can unexpectedly render a piece of imaging equipment “clinically obsolete ahead of schedule,” Theadore said.
“The standard responses are scenario planning, close tracking of vendor roadmaps, phased adoption rather than fleet-wide bets, and a preference for modular, upgradeable platforms.”
Widening the Financing Toolkit
Other challenges can include spending cuts, inter-departmental reallocation of resources, limited access to borrowing power, or reduced profitability; Theadore suggests that the antidotes to these include “widening the financing toolkit to include operating leases, managed-equipment-service, and as-a-service models that move spend[ing] out of the constrained capital line.”
Among these concerns, he also enumerates “long lead times and supply-chain fragility (addressed by ordering earlier, building in buffer and holding vendors to service-level agreements); reimbursement, regulatory and policy change, including certificate-of-need constraints and tariff exposure (addressed through scenario modeling and active monitoring); construction interdependencies (addressed through integrated facilities planning so the room and the machine arrive together); and the human problem of organizational politics, in which capital flows to the most persuasive director rather than the highest-scoring need.”
“The defense against that last issue is the same objective scoring methodology that defends against the others: making the criteria explicit and the decision evidence-based removes the lobbying from the room,” Theadore said.
“Mergers and acquisitions, finally, multiply all of this by introducing product variation and inconsistent data across acquired sites, which is why portfolio-level standardization belongs in any serious integration plan.”
The Cost of Weak Forecasting
“When an organization lacks the forecasting strength to build a real replacement timeline, the failure mode is both predictable and expensive,” he said. “Capital becomes reactive: equipment runs to failure, is replaced under emergency conditions at premium pricing with no negotiating leverage and long lead-time exposure, and patient care is disrupted by downtime in the interim.
“Budgets are blown by surprises, a deferred-maintenance backlog accumulates, and assets are pushed unsafely past their end-of-service dates, creating both a patient-safety and a cybersecurity exposure once a device can no longer be patched,” Theadore said.
“Allocation drifts toward politics because no objective evidence anchors it. At the enterprise level, lumpy and unplanned capital spending is precisely what pressures margins and concerns the rating agencies that assess how disciplined a system is with its capital,” he said.
“The remedy is not a larger budget but the data discipline and the rolling forecast that allow an organization to see the wave coming while it still has the time, and the leverage, to plan for it.”
Building an Integrated Capital Planning Framework
Marc Schlessinger, principal consultant & investigator for the Boston, Massachusetts-based Staritas, said that some of the most reliable tools, principles and strategies upon which organizations rely in capital planning function most effectively when integrated into a cohesive framework rather than applied individually. Techniques including predictive replacement planning (PRP) models, asset life cycle management systems, and analytics tools that incorporate utilization, failure rates, service costs and OEM support data all can help generate risk-adjusted forecasts.
To these, he added foundational operational principles, including total cost of ownership (TCO) and return on investment (ROI) calculations, risk- and value-based equipment prioritization, standardization, and scenario modeling as “critical to ensuring decisions are both financially and operationally sound.”
“Leading organizations operationalize these by embedding them into cross-functional capital governance structures – bringing together finance, HTM, clinical leadership and supply chain – while maintaining rolling, multi-year capital plans that are continuously updated, enabling them to align equipment investments with strategic goals, optimize spending and proactively manage risk rather than reacting to it,” Schlessinger said.
Aligning purchasing budgets with complex evaluation metrics like ROI and TCO helps to “translate clinical and operational value into financial terms at the point of acquisition,” Schlessinger said, in that ROI can help model “expected [imaging device] benefits, such as increased throughput, reduced downtime and revenue preservation, while TCO captures the full long-term cost of ownership including purchase price, service contracts, maintenance, downtime risk and eventual replacement.”
“In mature capital planning models, these metrics are used together to justify investment decisions and prioritize projects that deliver the greatest net value over time, not just the lowest upfront cost,” Schlessinger said.
“When an organization lacks strong forecasting capability to build a reliable replacement timeline, capital planning becomes reactive; assets are often replaced only after failure or acute risk emerges,” he said, “leading to higher emergency spending, extended downtime, inefficient use of older equipment, and missed opportunities to optimize clinical performance and negotiate favorable procurement strategies.”
Taken together, the four perspectives converge on a single theme: effective medical imaging equipment replacement planning depends far less on the size of a budget than on the discipline behind it. Whether an organization forecasts on a five-year or seven-year horizon, the leaders who consistently come out ahead are those who anchor their decisions in reliable data, keep the C-suite in clear line of sight, and treat the replacement plan as a living document rather than an annual scramble. Done well, that discipline turns the next equipment transition into a scheduled event instead of a costly emergency, giving an organization the time and the negotiating leverage it needs precisely when they matter most.
