Revisiting deconstructed PACS: Part 2

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If there's one constant, it's change, and with change comes diversity. Independent vendors exist in all of the major areas of modular PACS solutions, with market forces influencing the growth of the top players and a mix of success and failure for others.

Brad Levin of Visage Imaging.Brad Levin of Visage Imaging. Still other vendors have been acquired as a number of larger companies went on buying sprees, acquiring niche firms specializing in vendor-neutral archives (VNAs), workflow, viewers, analytics, and DICOM plumbing. Some vendors may continue selling multiple modules independently, while others offer them together as single-vendor modular solutions.

There are also several large PACS vendors that are publically for sale, others pondering potential sale, and some that have announced they are seeking "strategic alternatives." A few vendors have developed new technologies that show promise, while others have continued to stagnate technologically but have been aggressive on price to try to remain relevant in a competitive market.


A fundamental component of any informatics solution, interoperability has made great strides of late. Modern diagnostic viewers and VNAs supporting Imaging Object Change Management (IOCM) have ensured that the days of performing manual quality control changes separately on the PACS/diagnostic viewer and on the VNA are numbered. Increasingly, VNAs and viewers are also supporting XDS-I, but how many institutions use it in production? Not many.

Image viewers have dramatically improved accessibility to imaging results from the electronic health record (EHR), but performance and features vary widely. While viewing non-DICOM images and medical multimedia objects is of great interest for enterprise imaging, these orders-based and encounters-based workflows are still years away from being widespread. Also, many healthcare institutions are reluctant to unleash the full value of mobile devices for accessing imaging results, with security concerns hampering the promise of improved patient care.

On a positive note, there have been encouraging developments in web services and HL7's Fast Healthcare Interoperability Resources (FHIR) standard to further enhance application integration. The chasm between informatics solutions has never been closer with the capabilities of modern interoperability.

Future vs. today

In 2018, enterprise imaging has firmly taken hold of product road maps and shaped the industry's imagination. The Enterprise Imaging Workgroup, a collaboration between the Healthcare Information and Management Systems Society (HIMSS) and the Society for Imaging Informatics in Medicine (SIIM), developed seven groundbreaking white papers in 2016 to describe the state of the art.

Whereas once upon a time we were enthralled with the possibilities of big data and the cloud, the current rage is now artificial intelligence (AI) and machine learning. These efforts have spawned dozens of start-ups and academic data science initiatives, all working to develop new algorithms to best tap into the raw computational power of graphics processing units (GPUs).

While there's tremendous excitement (and, for some, trepidation) about the future of these technologies, the reality is most imaging organizations are still struggling with today. Imaging experts have repeatedly vocalized the lack of readiness of today's imaging infrastructure. Existing systems have become burning platforms being used well beyond their intended life cycle, as institutions struggle with massively large current/prior modality datasets.

Many institutions are wondering the following:

  • What are our options the next time our PACS goes hard down?
  • My PACS database is nearing full capacity. What can I do about it?
  • Do I reduce scheduling slots for digital breast tomosynthesis (DBT) so I can get priors sent in time?
  • Do we refresh hardware again but keep struggling with the same old architecture?
  • How am I going to support the new hospital we're building and the newly acquired system across town?
  • Do we partner or merge with the regional outpatient group competition, or consider the commercial buyout offer on the table?
  • Should I take the next upgrade, or make a system change to support the future growth that's planned?
  • Will a "good-enough" strategy allow us to tread water, or should we choose a long-term strategy of differentiation to allow us to compete and scale?

These questions remain the foremost concerns of most institutions -- not "how am I going to implement this new lung nodule AI algorithm?" Make no mistake, AI is the future, but for most institutions, establishing a solid enterprise imaging foundation is their No. 1 priority.

Replacement initiatives over the past few years have been encouraging. There are impressive success stories of academics, large health systems, and outpatient groups that have transformed their imaging services, some of which were presented at the SIIM and RSNA 2017 conferences.

Many have chosen a modular strategy, whereas a few have chosen traditional routes. These transformers have blazed a path of success for other likeminded imaging organizations to follow.

Best practices will eventually work their way to smaller institutions that are seeking PACS replacement, many of which will choose proven modular systems that have been designed to work in an interoperable, multivendor environment. Or they may adopt cloud-based delivery models (as bandwidth availability to the cloud continues to improve and becomes more affordable), with VNAs and other modular components installed, maintained, and delivered remotely.

While the jury is still out, it's no longer a question of if but when we will see imaging organizations prepared to make the leap to the cloud, which, until now, most have been reluctant to do.


Far from being merely aspirational, best-of-breed/modular or deconstructed PACS strategies have broken down the barriers of traditional PACS, revolutionizing enterprise imaging. The modularization of imaging informatics solutions has accelerated, from the actions of innovative, independent vendors and the acquisition of independents by traditional vendors, as well as the promoted modularization of traditional all-in-one solutions. The benefit to imaging organizations is that modularization has led to more choice and flexibility, supported by recent strides in interoperability.

In the end, it's not about the vendors involved -- it's about proven solutions working together that comprise an institution's best path forward. Solutions may come from one or multiple vendors, as long as the components are truly modular and interoperable.

It is a healthy practice to ponder what's on the horizon. What is the next disruptive imaging modality? Beyond DBT? 7-tesla MRI? What will happen once the access and display of non-DICOM/medical multimedia objects is widespread? How will AI affect clinical practice?

No one knows for sure, but there is certainty that legacy PACS solutions designed in the last century are ill-equipped for the future of imaging. The history of PACS has proved there will never be a single platform that does everything well today, as well as everything well in the future. This is an unrealistic expectation and misses the mark.

I'm sure today's institutions never imagined they would be using their PACS for 10 to 20 years, when PACS replacements years ago averaged a brisk five years. How's that flip phone still working for you?

Don't fall victim to the mistakes of the past that limited flexibility and restricted your options. If you don't have a solid imaging foundation, there's no better time than now to firm things up, with an infrastructure that has the flexibility to change.

Be strategic with your informatics decisions by choosing proven solutions designed to work in an interoperable, multivendor environment. That way, when a better modular solution becomes available, you can seize the opportunity. You and your patients can't afford to wait 10 to 20 years to benefit from the next big thing!

Brad Levin is the general manager, North America, for Visage Imaging. He is a frequent industry speaker and author, with a more than 25-year imaging career spanning government, consulting, and commercial roles.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of

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