Anyone who was raised by Depression-era parents like I was can probably relate to the statement, "If you can't buy new, then you make do." That's also the new mantra for PACS: Facilities must maximize the life and performance of their existing systems while minimizing financial, technical, and operational resources.
There are a number of reasons why PACS are lasting beyond their typical five-year life span. First and foremost, there's no real available capital, or the capital that is available is extremely limited. Unlike my sons, who will spend $70 on a pair of jeans that look like they came out of a Goodwill reject bin, my mom always used to patch our jeans when they got holes. Everyone in school had patches, so for me patches were the norm.
Of course, it didn't take long for us to need patches, because we didn't have cellphones and computers and we played outdoors where we tore holes in our jeans. The patches extended the jeans' life until they became either too tight or too short and we looked like orphans. Then and only then did we get a new pair. The new jeans were also expected to last until they became either too tight or too short and we looked like orphans.
It's that way with PACS too. Those in the C-suites are asking radiology and other departments the same questions: Do you need it or do you just want it, and can the life of the system be extended? If it can, then by all means extend it, they say.
This may not sit well with those brought up in the age of entitlement and who always want new, but those of us who have to make decisions on the PACS have to deal with reality and do what it takes to keep going. This leads a lot of facilities to look closer at PACS upgrades and updates as a stopgap measure.
Updates or upgrades
An update is merely going from one software revision to another -- 10.1 to 10.3, for example -- and it rarely requires hardware upgrades. It can be done by the PACS administrator and basically addresses known problems with the prior version of the software. These are almost always included in the service contract costs as well.
Most facilities do an update every second offering -- going from 10.1 to 10.5, for example, while skipping 10.3 -- as the incremental value in updating the software every time an update is available is usually negligible unless the software corrects a known problem they've been dealing with.
An upgrade includes additional features and benefits that have not been offered in a prior software revision (going from 10.7 to 11.2, for example). This typically comes with a nominal cost -- roughly 25% to 35% of the cost of new software -- and sometimes requires a hardware upgrade. Almost always, some assistance from the vendor is required to implement upgrades. Additional training may also be needed.
A cost-effective solution
Updates and upgrades can easily extend system life by 50% or more and offer a cost-effective solution to funding challenges and budget crunches, even if limited hardware upgrades are required. Incremental changes in not just the applications but also the operating system (OS), security, network, and more are to be expected.
Replacements are typically only done on systems that are 6 to 7 years old (or older), where the cost to support the hardware typically exceeds the value, where the OS may no longer be supported, and/or where there is a degree of dissatisfaction with the system performance, service, or other areas. In every case, the return on investment (ROI) has also been completely shown.
There are several other reasons why PACS are lasting longer as well. Internal IT resources that are required to assist with a new implementation simply aren't available. Just as radiology budgets have been cut, so too has IT staffing in many facilities. Resources that could be used for a new PACS are being redirected to help implement the integration of various clinical systems to create an electronic health record (EHR), while third-party help is often prohibitively expensive.
Hardware upgrades may also be necessary, especially if moving to 32- or 64-bit systems. These also require data and database migration, which is time-consuming and costly. Interestingly, the cessation of support for various operating systems has not been a strong motivator to replace existing PACS, although many vendors have pushed hard for it.
In fact, if anything, having new computers that support upgraded operating systems can be a detriment, since the applications software often hasn't been tested against the OS version shipped with the new computers (e.g., Windows 8 or newer versions of Internet Explorer). This requires older operating systems to be installed until testing has been completed on the newer versions.
Radiologists are also hesitant to change systems without reason. With reimbursement cuts and meaningful use (MU) and other programs affecting the operation of the entire department, radiologists cannot afford to slow their existing reading pace to come up to speed on a new system that could quite possibly hinder their throughput. This would lead to either more time reading or fewer studies read: two options that no radiologist I know is willing even to consider.
Developing a plan
So how do you make the most of your existing PACS? "Plan your work and work your plan" is the most obvious way, but sadly too many people set a goal that simply isn't achievable. Stephen Covey said it best: "Stop setting goals. Goals are pure fantasy unless you have a specific plan to achieve them."
To put a plan in place, you need to understand what you have system-wise, what tools you have to get there, and where "there" happens to be. Establishing time frames is nice but unrealistic. A few questions will provide you with the direction you need:
- What you want the system to do that it isn't doing now?
- What is required to stay compliant with state and federal laws?
- How does what you want the system to do fit with the long-term IT integration plan?
The first thing to do is look at the existing system. How is the system performance now? Does what I have now improve my workflow or hinder it? Will any add-ons cause an improvement or disrupt the existing workflow? What is the cost relative to the value?
Before you decide to update, upgrade, or replace, you should perform a thorough review of both your system and your workflow. This includes a technical and operational review, evaluating bottlenecks and other issues with the PACS, and holding a future-state discussion on how PACS fits into the bigger picture.
Ideally, this should be done on an annual basis, but truth be told, it rarely happens that often -- if at all. Sadly, that is like going out and looking at cars without knowing what you like and don't like about your current vehicle, what your budget is, and what you really need.
The technical review should look at the existing hardware and software, the archive, and the network. Evaluating the existing hardware requires you to look at the design and optimization, utilization, operating system use, installed applications, interfaces (and how these are accomplished either via an interface engine or HL7 interface), and the use of cache and prefetching. The latter two have created a great deal of discussion lately with the resurrection of RIS functionality in many PACS.
You need to look closely and ask if you are compromising performance with the existing hardware, and if the new hardware will provide you with a better-operating PACS. You also need to determine what you will gain by replacing or updating the hardware, and what value there is in doing so.
Evaluating the existing software requires you to look at what you are and are not using and, most importantly, how you are using it. In more than half the facilities I have been in, there are at least two software applications that are rarely, if ever, used and can be deleted or at the very least removed from the system startup to improve performance.
The archive review should include assessing the use of short- and long-term storage, the plans for disaster recovery and/or business continuity, the use of nonproprietary data compression, study-size changes, volume growth changes, and archive response time.
Network review looks closely at local- and wide-area networks and especially network security. This includes assessing what controls are in place to minimize any possible HIPAA breaches and the use of audit trails as well.
The operational review should focus on workflow and examine the entire process from sign-in to sign-out. It should also include a review of how transcription and reporting are done, the use of advanced software applications, how the facility is addressing federal and state legal requirements, radiologist hanging protocol use, change-management policies and procedures, and defined roles and responsibilities for interdepartmental, intrafacility, and external activities.
A small five-minute change in workflow can yield tens of thousands of dollars of cost savings per year, so reviewing the process from sign-in to sign-out is crucial. This includes the actions taken by the front-desk clerks, technologists, radiologists, transcriptionists (if used), and even primary care physicians (PCPs).
The reporting review looks at the report turnaround time (TAT) and ways that TAT can be improved by the use of speech recognition, automated sign-offs, and other methods. The use of medical image sharing, which eliminates CD creation and sends images directly to the PCPs and others via the Web, should be a serious consideration, especially in light of the rapid ROI this technology provides.
Advanced software use such as orthopedic templating, the use of mammography-specific applications, and advanced visualization (3D) should also be evaluated relative to its cost-to-value ratio and implemented where applicable.
Meeting federal and state legal requirements is crucial for any facility. CT dose management has been mandated already by two states, with many others shortly to follow suit. This will no doubt be extended beyond CT as well, so radiographic dose management software needs to be evaluated.
In addition, software that helps meet the Mammography Quality Standards Act (MQSA) can affect reimbursement, so that, too, needs to be examined. Critical-results reporting, emergency department discrepancy reporting, and even peer review all play a key role, not just in meeting legal requirements but also in the quality-control aspects of a department.
Once a system is implemented, it's rare that radiologists' hanging protocols are changed, often remaining the same for the life of the system. The PACS administrator should be updated annually by the vendor on ways that changes to hanging protocols can increase radiologist throughput. They then need to present these changes to radiologists for their consideration.
Policies and procedures as well as roles and responsibilities should also be reviewed annually, as they can be affected by personnel changes.
Future-state discussions deal with how the systems can be integrated together to create a seamless EHR, as well as where they expect a facility to be in five, seven, and 10 years. While prognostication is good, it's difficult to be totally accurate due to the fluidity of the healthcare marketplace. That said, a facility should still have a good idea where they want to be and what it should take to get there.
One of the most widely evaluated technologies today is a vendor-neutral archive (VNA). Used to replace the multiple independent and often proprietary data silos associated with various disparate clinical systems, a single VNA has many benefits. These include a lower total cost of ownership, cost-effective scalability, vendor independence, and the ability to migrate to another PACS without incurring data migration costs.
Most importantly, the VNA can facilitate easier data sharing via a single login for the primary care physician, a capability that can improve patient care. It also offers more cost-effective and easier disaster recovery options as well.
Future-state discussions should also include proposed software add-ons and the prioritization therein, i.e., where you get the most bang for the buck. At the C-suite level, discussions should include the future role and integration of radiology services into the overall EHR. This includes how images and reports can be delivered to the desktop and also to mobile devices.
A great deal of the process in assessing how to make the most of your existing PACS can be performed internally. However, outside resources typically bring a different and unique perspective to the process and offer objectivity as well. The quality of information provided from an outside resource and the prices charged vary widely, often with little correlation between the two. That said, if you clearly delineate what you want and need from them and do not let them guide you as to what they feel you should have, you'll save both time and money.
Act on your decision
As you look at your existing PACS, think through what direction you want to go in, analyze your requirements, and then put together a plan of action. Above all, act on your decision. Analysis paralysis is deadly and can be more detrimental to an organization than not entirely making or dragging out a decision.
Making do isn't really about just making do. It's about making sense. Like patches on jeans, you hold the system together until you've either outgrown it or it becomes too tight. Then it's time for a replacement. Just make sure the next system you chose fits you well and also has a little extra room for all-around growth. After all, it may need to last you a while.
Michael J. Cannavo is known industry-wide as the PACSman. After several decades as an independent PACS consultant, he spent two years working as a strategic accounts manager with a major PACS vendor. He has now made it back safely from the dark side and is sharing his observations in this Straight Talk From the PACSman series.
His healthcare consulting services for end users include PACS optimization services, system upgrade and proposal reviews, service contract reviews, and other areas. The PACSman is also working with imaging and IT vendors developing both global and trade show-specific marketing programs using market-focused messaging. He can be reached at firstname.lastname@example.org or by phone at 407-359-0191.
The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.