Straight Talk From the PACSman: Is PACS dead?

2015 08 17 15 59 36 90 Tombstone Rip 200

At this year's Society for Imaging Informatics in Medicine (SIIM) annual meeting, the keynote speaker discussed the coming shift away from traditional PACS, including why it will happen and how to prepare for the change. While the speaker said it was premature to predict the demise of PACS, he did indicate the technology's future will be different than what you see today.

That isn't exactly earth-shattering news, as I and most others in the industry agree that PACS now has a different form factor than it did three years ago and will have a different form factor three years from now. This is very similar to how many marriages evolve as well. Conducting an "autopsy" for PACS, though, is a bit much, even if the word was used solely for shock value.

An autopsy on PACS?

Merriam-Webster defines an autopsy as "an examination of a body after death to determine the cause of death or the character and extent of changes produced by disease; a critical examination, evaluation, or assessment of someone or something past." If this is the case, should we be ready to break out the defibrillator for PACS to try and keep it alive, or is it better to "start planning the funeral for PACS," as one journal suggested?

PACS consultant Michael J. Cannavo.PACS consultant Michael J. Cannavo.

Not at all. PACS is very much alive and well, and it will be for quite a long time.

PACS provides the foundation of any enterprise imaging strategy. That is good news for hospitals, considering that both cardiology and radiology are two of the leading revenue sources for the typical facility. But having a strategy and implementing it are two entirely different things.

There is no question that the use of vendor-neutral archives (VNAs) is on the rise. Migrating prior data into a VNA is required to make a VNA fully operational, but this is neither cheap nor easy.

While eliminating the various data silos that are attached to each individual clinical system is one of the ultimate goals of a VNA, having a single data repository for an entire hospital's data also has its technical and operational limitations as well. That is why a PACS that incorporates a VNA is often configured so that less than 10% of all queries need to retrieve images from the VNA, and why many employ a strong prefetching algorithm as well. There also needs to be a strong disaster recovery plan for the VNA if it is to be the central data repository for all hospital data.

Radiology and cardiology PACS providers are strong proponents of VNAs, but adoption from vendors in other clinical areas, including the electronic medical record/electronic health record (EMR/EHR), has not been quite as strong, and other clinical systems haven't embraced it as widely either. Defining what actually constitutes a VNA still remains an issue, as there has been no widely accepted industry-standard definition of what a VNA is or does as yet. This also impacts widespread acceptance as well.

3 market forces

There have been three external market forces cited for the purported demise of PACS:

  1. Money, due to the transition from volume-based to value-based payments in healthcare
  2. Adoption of EMRs and EHRs, which is crucial to any enterprise-wide solution
  3. Industry consolidation among healthcare providers

1. Money

Let's look at money first. No one will argue that payment reform is inevitable, but it will take several years for this to even begin to take effect, let alone result in value-based radiology becoming the industry norm.

Truthfully, I also haven't been able to figure out how or why radiologists should be evaluated and reimbursed based on their providing appropriate patient care when they aren't the primary care physicians responsible for the patient. That is another story for another day though. Just like with PACS, you have to get creative in your approach to replacing one declining revenue stream with another.

One of the primary means of generating additional revenue is using patient data to help determine the best course of action relative to a treatment plan. This analysis of patient data, known better as data analytics, is one of the hottest areas of interest that facilities are looking into. Studies have shown that data analytics can provide a 25% or greater increase or more in a facility's net revenue simply by adjusting and tailoring the treatment plan based on patient information.

Data analytics evaluates cost, quality, labor, and enterprise resource planning, among other services. There are several types of analytics. For example, performance analytics provides performance measurement and improvement, care coordination, quality reporting programs, continuing medical education, back office functions, maintenance of certifications, and registry reporting.

Predictive (or prescriptive) analytics ties metadata to clinical priorities and measurable events such as cost effectiveness, clinical protocols, or patient outcomes and includes evidence, recommendations, and actions for each predicted category or outcome.

One example of this is providing a generalized predictor of hospital readmissions, length of stay, and clustering of patient outcomes to historical cohorts at time of admission. Service-line analytics enable assessment of the true cost of a service, such as understanding whether cardiology services across an enterprise are profitable. All of this information is key in helping to keep the hospital profitable.

Having the patient data is only one part of the equation, however. Having access to prior studies in the VNA also is needed to avoid costly study replication.

In addition, image analysis tools such as computer-aided detection (CAD) can also improve the quality of patient care as well, much in the same way it did with mammography before reimbursement cuts significantly impacted the expansion of that technology.

2. Adoption of EMR/EHR

EMR adoption is the next external market force to consider. According to a 2014 news release from U.S. Office of the National Coordinator for Health Information Technology (ONC):

More work is needed to support widespread health information exchange and providers' ability to achieve stage 2 meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs. ...

In 2013, health information exchange among physicians was relatively low: 4 in 10 (39%) reported they electronically share data with other providers, but only 14% electronically share data with ambulatory care providers or hospitals outside their organization.

In 2013, the vast majority of hospitals had capabilities that could be used to support many meaningful use stage 2 objectives but were not being used. However, 10% of hospitals were providing patients with online access to view, download, and transmit information about their hospital admission.

While 78% of office-based physicians reported they adopted some type of EHR system, less than half of all physicians (48%) had an EHR system with advanced functionalities. About 6 in 10 (59%) hospitals had adopted an EHR system with certain advanced functionalities, according to the ONC. That still leaves a lot of physicians and facilities to come on board in three short years.

Many facilities also still have separate hospital, radiology, lab, and other clinical system, yet are interfacing these to create an EHR system as well. However, that EHR isn't necessarily one that is comparable to a full-blown turnkey EHR as offered by a handful of vendors in this marketplace.

Which statistics you trust is up to you, but let it suffice to say that EMR/EHR adoption is not nearly as widespread as one might be lead to believe.

While EHR adoption has seemingly grown in leaps and bounds over the past several years, adoption has also slowed down by nearly 50%. EHR systems for hospitals aren't cheap either, costing millions of dollars, with implementation costs often exceeding the system cost itself. That typically takes several years of budget cycles just to prepare for alone. An EHR system can also literally take several years to implement, so that needs to be factored in as well.

One burning question that also needs to be addressed is what happens when the meaningful use (MU) incentives either go away or are significantly delayed as they have been already? What impact will that have on technology adoption? Spending money to make money makes sense, especially when related to obtaining MU incentives, but a lot of what is being done now to capture MU revenue won't show the same return on investment (ROI) without it.

A considerable amount of promotion has been done about the capabilities of EHRs (and VNAs) to integrate, archive, and view hospital information and image data. That simply isn't being done on a widespread basis today, and it may take several years for more than just a few vendors to demonstrate the capability to do this. Data migration also isn't a cheap, easy, or fast task to do and needs to be factored in.

Looking at all the data will also require a specialized viewer that can easily change from viewing structured patient information and clinical data, scanned images from the enterprise content management systems, and both DICOM and non-DICOM-based images coming from radiology, cardiology, pathology, and others.

This also includes viewing capabilities on mobile and tablet devices. I may have missed it, but I don't believe this viewer currently exists. Switching viewers based on the type of data being viewed is going to be awkward at best.

A single image and data repository is going to also place high demands on the existing network as well. This also needs to be factored in, and upgrades planned for.

Last, but not least, with any clinical system there needs to be some form of redundancy in the event the system goes down so that a department doesn't go down with it. Proactive monitoring is going to be crucial, yet just a few vendors offer this currently.

3. Industry consolidation

Consolidation among healthcare providers is not new by any means. Still, interfacing or integrating disparate systems is no small task, especially when you have systems in which the database can only be accessed by the vendor or where there is something proprietary in the system design. Creating a single master patient index (MPI), establishing a reliable local and wide-area network, and other tasks also need to be considered as well.

Hospitals have been going through mergers and acquisitions for years, so they have a comfort level doing this, but, frankly, the technical side is fairly easy given enough money and resources. It's much more challenging to implement a multifacility workflow -- especially if the facility that has been bought has a different radiology group reading for them -- including creating a single MPI and eliminating multiple patient IDs.

I wholeheartedly agree that planning for an enterprise-wide solution needs to start now, but putting an arbitrary date on when the change may happen does a disservice to the entire industry. Keep in mind that most clinical systems have a life of five to seven years, so whatever happens now has to last at least that long.

It's a lot easier said than done to ask different departments to put on their blinders and reach out to each other to make this work. Unless a plan is developed by the chief information officer, chief technical officer, or others and implemented by them within a realistic timeline, then nothing will happen.

Detrimental effects

Hospital administrators, seeing headlines about planning funerals for PACS or the world as we know it ending, might tend to put a hold on plans for PACS upgrades and updates, as they won't be sure what to do and when. This would have a detrimental effect on both the radiology department that needs the technology and the vendors whose role it is to keep the department operating as smoothly as possible.

Anyone who has had kids knows that concepts are great, but nothing prepares you for the reality like living it. I've been living with PACS for 30 years and with my kids for over two decades. Nothing prepared me for the wild ride I have had with either.

All the books in the world can show you the basics and provide you with great concepts, but sadly a lot of the stuff I needed to know wasn't in there. You learn it from the school of hard knocks. With PACS, I asked a lot of questions and put together a plan that was customized for each facility, since no two facilities are the same and one size does not fit all. The same can be said for my kids.

With them, when in doubt, I would drop back to how I was raised, with an occasional swat on their backside using the book that showed me the basics just to get their attention. Now before you place a call to the department of children and families on me, know it must have worked because my youngest son just started medical school last week and my eldest son is on a solid career path with Apple. So there.

Every now and then, PACS needs a swat on the backside, and we need to revisit our plan for raising it so it continues to becomes a productive member of the hospital enterprise. The future is in PACS and will be for quite some time.

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 [email protected] 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

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