Straight Talk From the PACSman: PACS and proverbs

2014 02 05 15 59 49 6 Cannavo Mike Rsna13 200

Growing up in an Italian household, my brother and I were subjected to more than our share of proverbs from the "Old Country." Among the more popular ones were: "Ask me no questions, and I'll tell you no lies" and "Fool me once, shame on you; fool me twice, shame on me." These proverbs are crucial for those going to RSNA 2015.

When I hear end users say, "They lied to me" about a PACS vendor -- and I have heard more than my fair share of this over the past decades -- I have to check to see if they've asked the questions that would have gotten them the answers they needed to know. If not, then whose responsibility is it? Is it the vendor's or the end user's?

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

Carrying this one step further, is it a sin of omission not to answer a question that wasn't asked? There is another saying: "A fish would never get in trouble if it wouldn't open its mouth," and most salespeople only answer questions that are asked and volunteer nothing more.

When is it right and when is it wrong not to share all information or to withhold information that may make a difference in meeting the customer's application? If the salesperson knows the application that the customer wants for the product or service and purposefully withholds pertinent data about what the product or service can't do, then that is wrong, at least in my book.

Sadly, in more cases than not, the information contained in a request for proposal (RFP), technical spec, or other means for the end user to obtain a quote from a vendor is almost universally more technical and financial in nature than operational. Outlining the operational functionality of the system to the vendor is crucial. The more specific you get relative to the operation of the PACS or vendor-neutral archive (VNA), the closer you will come to getting the PACS you need.

Asking the wrong questions

What is funny in a not-so-funny way is when end users use the exact same RFP for a replacement PACS that almost never asked the right questions to begin with. "We have had PACS installed for X years -- we know what we are doing."

All I can do is smile when I get a call a year later, saying the facility is not happy with the new PACS and they need to hire me to arbitrate a solution. In nine times out of 10, very little can be done legally except appealing to the vendor's sense of fairness and hoping that we can come up with a solution that is amenable to all parties. The bottom line is, you stand a much better success rate of having a golden anniversary with a mail-order bride than in finding happiness using the same old criteria for a new PACS.

Why, then, is a new or at least revised RFP required? Changes happen almost daily with PACS. Interoperability standards like Fast Healthcare Interoperability Resources (FHIR) didn't even exist when the last PACS was selected, yet support of this HL7 interoperability standard is crucial.

The use of data analytics, which is key to optimizing departmental operations, was also in its infancy just a few short years ago. Data dashboards that provide proactive versus reactive forbearance relating to PACS operation were also relatively new. Integration of new clinical studies such as breast tomosynthesis into the PACS was virtually unheard of until recently.

In fact, the list of advancements with PACS is endless while the RFP remains unchanged. Because of that, often the vendor with the best solution is not selected. If the end user didn't present the problems to the vendors properly because they didn't know what was available to solve the problem, then what my momma said about pinning the blame on others holds true: "When one finger points to another, four fingers are pointing back at you."

It's incredibly easy to be overwhelmed at the RSNA meeting. I've been going for nearly three decades now, and I still remain overwhelmed. There are over 650 vendors this year, all competing for your time, and the solutions being presented may not be familiar.

Doing research ahead of time is key. Read about what is going on in the imaging industry, specifically industry trends. Try to grasp not just the technology itself -- that is actually the easy part -- but how the application of the technology has been shown to solve problems in similar facilities.

White papers can only take you so far, so get with the vendors and have them identify sites that have actually used the technology. Ask those customers how they justified the purchase; what was the good, the bad, and the ugly about the implementation process; and, most importantly, what they would do differently from the time they considered using the technology to where they are now.

Understand it's not the technology itself that matters; it's the application of the technology that is crucial. Nowhere is that statement more applicable than data analytics.

Data analytics

There are many types of data analytics, but the two most prevalent are descriptive analytics, which provide data on revenue, profits, and other key performance indicators, and predictive analytics, which ask "what if" questions and look toward the future. Both types of data help optimize business strategies. They also help assess whether predicted business outcomes are worth pursuing, and include everything from pinpointing patients who have a high risk of readmission to targeting services to a particular market segment.

Data analysis is becoming more and more important as hospitals continue to look for ways to cut costs and/or increase revenue. While having the data is one thing, doing the data analysis is another.

Many hospitals do not have the capability to perform the detailed analysis required from the data and often outsource this to third parties. This will change when advanced algorithms and analytics similar to the Statistical Package for the Social Sciences (SPSS) become more integrated into the data analysis packages being offered.

Regardless of how the data are presented, the information always needs to meet four key criteria -- be measurable, purposeful, accountable, and understandable -- or its value is significantly limited.

One of the challenges of obtaining data from various clinical systems is having to query the various data silos where the data reside. Having a central data repository for all clinical data is one of the key advantages of a VNA, enabling significantly easier access to the data as well as providing a cost-effective disaster recovery solution. It also is much more cost-effective than supporting individual data silos. Numerous articles have been written on the advantages and benefits of VNAs, but the technology should still be at or near the top of every facility's evaluation list.

PACS end users must also understand the difference between an onsite hardware-based solution and a cloud-based solution. Each offers its own set of advantages and benefits -- and certain disadvantages as well. With regard to a central data repository, most end users fail to do two things that are crucial.

First, if you elect to implement any VNA, you must have full access to the database. Most companies promote the ability for the end user to migrate the images off the VNA in a DICOM Part X file format, but when it comes to the image database, that often is another story.

Second, with cloud storage you need to negotiate the cost of data migration ahead of time. This can be in terms of cost per study; cost per terabyte; or, best of all, a not-to-exceed cost in the event migration costs go down as they have in recent years. You also need to negotiate the amount of time the migration will take, with penalties for failure to meet the prescribed time frame.

There have also been a plethora of mergers and acquisitions of late. This has led buyers of the companies that have been assimilated to ask, "What happens now to the product I recently purchased?" The answer is simple: No one really knows.

You no doubt will get assurances from the company that sold you the product, but there is no legal requirement on the part of the acquiring company to support a product or service. A promise in writing is only as good as the acquiring company wants to make it.

Thankfully, most of the acquisitions that have been made recently have involved firms that want to keep their new companies intact and offer the same goods and services, at least for the near term. Thankfully, most vendors will also support an existing product for an extended period of time as well.

Security issues

Bloomberg Businessweek recently published a great exposé on hospital data security breaches. Data security and HIPAA compliance are at the top of every hospital's to-do list. With fines of up to $10,000 per security breach, it's no wonder why.

Still, the article exposed many different ways that hospital data have been breached. While an end user can and usually does have a business associate agreement (BAA) with a provider, you need to understand that the entity having access to the data can only do so much to protect the data from outside breaches.

In addition, the BAA is only as good as the company that stands behind it. The deepest pocket always gets included in the lawsuit, so probably the best course of action you can take is to ensure there has been extensive security testing on the products being used.

With the development of the electronic health record (EHR), in which numerous clinical systems all feed into one primary system, I have seen several sites take the same singular approach with imaging. Facilities have negotiated deals to buy radiology PACS, cardiology PACS, a VNA, and other imaging-related products such as specialized software from a single vendor. In theory this makes sense, as it give you "one throat to choke," but in practice the only throat that will probably be choked is your own.

While there are a lot of good radiology PACS, cardiology PACS, and even VNAs in the imaging space, I have yet to see any one company where every one of their products is exceptional or even in the top three in all categories. What this often leads to is the installation of one exceptional system, one marginally acceptable system, and one system where, in my most politically correct verbiage, "a much better choice could have been made."

In an age where interoperability is the focal point, it really makes no sense to implement anything less than the very best for each area, and integrate them together. This best-of-breed approach forms the basis for the buzzword term "deconstructed PACS," where the archive, workflow, and viewing needs are looked at separately.

How far you go in acquiring individual components to create the best solution varies by facility, available resources, money, and other areas, but with interoperability being much easier now than ever before, this can be done fairly easily. The bottom line is that there is no need to go with a single-vendor solution for all of your imaging needs or even within a single imaging system itself, especially when you recognize that the cost savings are negligible. You can get the best for the same or less.

Is this approach more labor-intensive? Possibly in the short term, but not as much as one would think in the long term. Most importantly, you aren't beholden to a single vendor who has total control over some of the most important clinical systems in your facility. The Latin proverb animum per globos iaculis sequitur sums it up best. Roughly translated, it means that your heart will follow when other parts of the anatomy are in someone else's hand.

I grew up with hundreds of other proverbs, but frankly most aren't fit for publication either in English or Italian. Some of the cleaner ones I have heard and used with vendors and clients alike include "A lie has short legs," "A fish smells from the head down," "The best goods are the cheapest in the end," "A bad beginning makes a bad ending," and, my personal favorite, "One may have good eyes and yet see nothing."

To see properly, we need to look in the right direction. That direction comes from asking the right questions and sharing as much as you can about yourself. Momma was right when she said, "Between saying and doing, many a pair of shoes is worn out." Let's hope your shoes hold out in Chicago this year, and that more doing is the end result of RSNA 2015.

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 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

Page 1 of 783
Next Page