Part III: Exploring PACS secrets presents the third part in a series by PACS consultant Michael J. Cannavo exploring commonly accepted PACS theories -- as well as industry secrets your PACS vendor might not want you to know.

In no other medical industry have so many consultants come and gone as quickly as they have in PACS. While perhaps a dozen or so legitimate PACS consultants or consulting groups are in today's marketplace, for every one "legitimate" PACS consultant at least five ex-sales reps have hung up their PACS consulting shingle (at least until the next real job comes along).

Even some of the legitimate PACS consulting groups have become a revolving door of individuals coming and going (and in some cases coming back again), offering global expertise in many areas. Yet few, if any, individuals have expertise in dealing with a full-blown clinical PACS implementation.

With free resources abounding for return on investment (ROI) models, requests for proposals (RFPs), and virtually every other "tool" one can think of for selling PACS and helping you along the way, why then do you even need a PACS consultant? In many cases, the reality is you don't.

If the depth and breadth of resources are present within the facility from both a radiology and information technology (IT) resource standpoint, and there is at least one individual from each area who can and will oversee the entire PACS process, knows what to expect, and how to evaluate PACS properly, then the answer is no. If any of these are missing, though, you probably can benefit from using a consultant.

Consultants are typically utilized in six key areas: project planning, workflow design/project re-engineering, RFP development, vendor evaluation, contract negotiations, and project implementation. How these tasks are performed varies widely from firm to firm, as do the associated costs.

Some facilities like to develop various charts, graphs, and statistical analyses, while others prefer to take the minimalist approach with a written synopsis of a few pages. Understand that an IT-driven project typically, but not always, involves volumes and focuses on technical aspects and justifications, while a radiology-driven project will focus on form and emphasize operations and functionality.

Again, it's mainly about who is in charge and to whom the consultant reports. Also keep in mind the exponential relationship between cost, development time, and content. Less is better.

Key areas

The PACS project plan evaluates what your facility has and where you want to go, and provides options and associated costs on how you will get there. And a consultant can help develop a plan that works for you.

A baseline project plan, along with a ballpark idea of costs, should be formulated during a daylong readiness assessment for PACS, with a more detailed plan taking no more than a few weeks to develop, if that. An exception to this would be a facility that wants detailed technical assessments of each modality's DICOM conformance statements, or a book defining the plan using Visio charts and the like.

Most consultants also offer a workflow design service. Keep in mind, though, that almost every PACS vendor (at least the big six) includes this service in their PACS proposals as a fixed (unmovable) cost. Do you need this service? Yes, so you can at least benchmark changes in process pre-and post-PACS.

Do you need the vendor to do this? Unfortunately, you aren't given much of a choice. It's always better to perform as much of the baseline charting internally as you can (no one knows your existing operations better than you do), then present it to the consultant (if desired) for his or her input. Again, time for this should be less than two weeks, depending on the content and format selected.

RFP development is an area that has gotten a lot of discussion, especially since so many RFPs are available for free via the Internet. Should you issue an internally developed RFP using a template? Do so only if you are extremely confident the template provides the vendor with all the information needed to properly provide you with a quote you can use. Also keep in mind, with RFPs, less is typically much better than more.

One-thousand-question RFPs that do not address operation and functionality have minimal value. A good rule of thumb is that a 20- or 30-page RFP, filled with detail, should suffice in 95% of the cases.

RFPs should take a week at the very most to develop as many consultants have their own templates (and vendors in turn often also have response templates to a particular consultant's RFP style). A great deal of customization, though, is still required to ensure that the level of detail a vendor needs to respond is included, so expect multiple revisions before this actually hits the streets.

Vendor evaluation is a key area where a consultant can play a role. The consultant's knowledge of the vendor's product is actually less important than his or her knowledge of your specific radiology operation and how PACS will fit. Surprised? Don't be.

Vendors can't even keep up with their own products, let alone having a consultant try and define their product. In addition, most hospitals have technical resources that put virtually all PACS consulting firms to shame. The breadth of knowledge a consultant brings to the table in all areas, especially radiology operations, is far more important than the depth of knowledge they may possess in any one area.

It's also critical to have someone knowledgeable involved in contract negotiations. Most hospital legal and purchasing departments have no idea about PACS requirements, nor do others involved in the process. Even though vendors typically make very few contract concessions (especially the majors), it's crucial to have a consultant working on contracting with you.

However, it's typically wise to avoid using a consultant for project implementation for two reasons. One, the vendor should be held accountable for their project success, not the consultant. Two, the potential for conflict of interests in implementing a particular vendor's PACS is much greater than if the engagement ends at contracting.

Finding a PACS consultant

So how do you find a legitimate PACS consultant? Surprisingly, it's not as easy as it sounds. Obtaining a consultant's credentials is critical, but credentials are only a small part of the entire picture.

Most people look at credentials from a purely volume standpoint -- how many projects has the consultant worked on. Instead, ask how many projects he or she has worked on from start to finish that are similar to yours, not just in terms of project planning, but full-blown implementations. Also confirm that the consultant has an understanding of your specific needs.

The requirements of a 150-bed regional community hospital vary greatly from a multisite, 1,800-bed conglomerate; a 500-bed teaching hospital; and a 400-bed VA facility. This is also why a facility that is part of a multigroup purchasing arrangement or corporate-owned entity should never engage a PACS consultant merely on the basis of a contract being established for their services.

Consultants should bring objectivity and fairness to the table; however, almost every vendor in the market can tell you which consultants seem to favor certain vendors. Because consultants get paid regardless of which vendor is chosen, this really shouldn't matter. Or should it? This is the ugly side of PACS consulting.

Many consultants work both sides of the fence: clients (hospitals and radiology groups) and vendors. In and of itself, this isn't bad until compromises are made that could possibly impact the consultant's objectivity and integrity.

Consultants or groups may have a "preferred vendor relationship" or "partnership" that they wish to preserve (and/or one they also obtain a financial benefit from). They can also have other projects with vendors that they do not wish to jeopardize.

Finally, the vendor and consultant may have an "arrangement" that is financially beneficial for the consultant once the deal has been consummated for the vendor. Vendors and consultants have both gotten smart in this regard in recent years. While nothing "auditable" is ever on paper, the consultant may be "engaged" after the fact to work on a vendor's "special projects" as a reward for helping the vendor win the deal.

Is this legal? Technically, yes. Is it ethical? Not really. This is one of those areas that no one ever discusses or acknowledges. Not surprisingly, backroom deals still go on today, and not surprisingly most involve the same few consultants.

Ask the right questions

Protecting yourself from these unscrupulous and shady dealings is fairly easy. First, ask for a list of all the vendors the consultant's clients have selected over the past two years. While a vendor showing up two to three times isn't all that bad (industry leaders typically don't become leaders for no reason), further investigation is required if more than half the contracts go to one particular vendor.

Second, have the consultant disclose any and all current and prior relationships they have established with vendors over the past few years, whether money was involved or not. The consultant should have no issues disclosing these relationships, even if it is something as innocuous as the vendor paying expenses to see the latest version of software or to visit a new installation. Look closer, however, if the vendor also pays the consultant's daily rate to help "educate" them.

Third, and most importantly, every consulting contract (including, but certainly not limited to, PACS consulting contracts) should have an independent contractor clause in them. This is the clause that our company has used since its inception:

INDEPENDENT CONTRACTOR - (CONSULTANT's) status hereunder shall be that of an independent contractor and not an agent or employee of (HOSPITAL). Neither (CONSULTANT) nor (CONSULTANT'S) representative(s) shall have any authority to enter into any contract or commitment on behalf of (HOSPITAL), and neither (CONSULTANT) nor (CONSULTANT'S) representative(s) shall hold itself out as having the authority to do so. (CONSULTANT) also represents that its services are performed solely at the request and in the interest of (HOSPITAL). (CONSULTANT) further certifies that: a) it has not received nor will it accept any financial remuneration other than that represented in this agreement in acting as an independent market consultant to (HOSPITAL); b) that (CONSULTANT) has no third party or other outside contracts other than those disclosed in writing to (HOSPITAL) prior to contract signing (or during the term of the contract) that may impede upon its role in providing objective information to (HOSPITAL); and c) that representation of the interest(s) of any vendor(s) in connection with the services (CONSULTANT) is contracted to perform for (HOSPITAL) is reason for immediate termination of this agreement.

So are PACS consultants worth the money they charge? The answer is no, for the most part. What's sadder yet is that most facilities equate the prices quoted with the value of the consultant when, in fact, the opposite is usually true.

The best consultants can come in and evaluate the situation, develop a plan, and put it onto action far faster than those who are being paid by the facility to learn PACS 101 on the job. Unfortunately to compete, the best have to charge high prices because lower prices tend to raise suspicions far more so than higher prices.

So how do you pay a consultant? It is better to pay based on achievement of defined benchmarks than providing them with a monthly retainer, even though PACS projects typically extend a lot longer than projected. This eliminates the need for weekly progress reports (no progress, no pay) and other unnecessary and expensive-to-produce documentation, while providing an incentive to stay on top of the project.

The decision to use a consultant is a complex one. The bottom line: it all comes down to gut feeling, as the relationship you have with your consultant will last years. Styles vary widely among consultants -- some are very formal and professional, while others are highly informal and personal.

To address these differences, it's always best to hold a conference call or, if possible, have the favored consultant perform a daylong baseline assessment for you. That way both parties can check each other out, and make everyone feel more confident as you embark on one of your biggest purchasing decisions ever.

By Michael J. Cannavo contributing writer
September 17, 2004

For "Part I: Exploring PACS secrets," click here.

For "Part II: Exploring PACS secrets," click here.

Michael J. Cannavo is a leading PACS consultant and has authored over 275 articles on PACS technology in the past 15 years. He can be reached via e-mail at [email protected]. In the event Mike can't be reached by e-mail, he obviously didn't make it through his third hurricane in the past five weeks. Rest assured at least five other PACS consultants are standing by waiting to take over both his e-mail and Web site (

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular vendor or industry consultant or consulting group. Rather, they should be taken as the personal observations of a guy who has, by his own account, been in this industry way too long.

Related Reading

PACS still a bridesmaid at HIMSS, February 27, 2004

The year of the Uni-PACS: A view from the RSNA floor, December 11, 2003

The PACSman's opinionated view from RSNA 2003, December 4, 2003

Copyright © 2004

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