Straight Talk From the PACSman: Here for the funeral?

2016 10 21 09 37 52 826 Cannavo Mike Rsna13 400

If you saw someone wearing an "I'm here for the funeral" t-shirt at the Society for Imaging Informatics in Medicine (SIIM) annual meeting to make a joke about the often-predicted demise of PACS, it wasn't me. But it could have been, had I gone to the conference.

Five years ago, the death of PACS was predicted prematurely, a diagnosis that was apparently based on innovations that were incorrect or, at the very least, several years too soon. Instead of the patient being brought to the morgue for an autopsy, PACS simply needed to be given an antacid and sent home.

Michael J. Cannavo.Michael J. Cannavo.

While few would debate that vendor-neutral archives (VNAs) and enterprise viewers are a much larger part of today's landscape than they were five years ago, more traditional PACS are still very much alive and kicking, though undoubtedly older and with a few more gray hairs.

In fairness to those who predicted the demise of PACS, things actually have changed over the past several years. Just like an older person relies on others to help him or her though the day, PACS now relies on other clinical systems to help the radiology department work more efficiently and to help the clinicians and patients who rely on it. This evolution was inevitable given the government regulations that now require the various clinical systems to work together.

So why was PACS declared dead before its time? To understand this, there needs to be an understanding of what a PACS is and isn't. While PACS utilizes digital technology, PACS is not simply about new technology. Were that the case, the technological innovations that were forecast five years ago quite possibly could have made PACS obsolete -- at least in its current form. But adoption takes time, and change is not always a good thing.

Additionally, financing for other projects that hospitals have budgeted for is being heavily scrutinized. As happens so often, much of the available funds targeted for PACS upgrades are being postponed or redirected to many other large, multiyear hospital-wide projects that are often related to the development of an electronic health record (EHR). These multiyear projects are much broader in scope and affect the entire enterprise.

Because of this dynamic, PACS is left to more or less chug along in its current form until the systems it needs to integrate with have been fully implemented. This can take anywhere from three to five years from the date the first piece of EHR software hits the computer room.

Still important

Keep in mind, this doesn't mean that PACS is any less important than any other clinical system; PACS remains crucial to the operation of any facility. Instead, hospitals are taking more of an "if it ain't broke, don't fix it" approach toward PACS as well as most other clinical systems -- especially if the current operational state is satisfactory. While there undoubtedly are upgrades that can provide a value-add to the PACS, if the costs don't show a tangible return on investment (ROI) in a relatively short span of time, then the decision to implement these upgrades will quite likely be tabled.

So what about PACS that are at or near the end of their useful life? Most of the available capital has already been claimed, so a vendor has to be creative in its approach if a PACS needs to be replaced due to hardware or an operating system that won't support the latest software releases.

A lot of sites have chosen, where possible, to eliminate onsite hardware and run in a virtual environment. While this eliminates the need for hardware support from already short-staffed IT departments, it also places a heavy reliance on a solid wide area network (WAN) connection. In larger metropolitan areas, that isn't as large a concern as it is in more rural ones. Even with a solid system design, though, you still should have a small server onsite that mirrors the remote one, albeit with very limited storage, etc.

The drive for PACS replacement seems to come more from vendors than the end users these days. Nearly every software service agreement states that the vendor will no longer support systems that are more than two software revisions beyond the current release, so that's what the vendors tend to lean on to get you to update, if not replace, the existing system.

It's a nice ploy to get you to update, but the reality is that even though the company won't provide additional software fixes (otherwise known as updates) to that old software version, they will continue to accept any and all service revenue and support it the best they can. However, many times updates will not be supported by the current hardware or operating system, so a "forklift update" might be needed.

Is an older PACS as good as a new one, even if it technically has one foot in the grave? Do you need to stick with the same vendor?

Yes and no. Routine maintenance can keep a PACS alive, just as it can extend the life of an old car. I typically drive a car at least 10 years before I replace it. Sure, it's nice to have new features such as Bluetooth, a rear-view camera, or self-braking, but do I really need them to drive?

The same can be said for PACS. There are certain requirements you absolutely must have and some that you should have given reimbursement-related changes, but those features you absolutely must have are few and far between. For any upgrade, the rule of thumb is that it makes perfect sense to proceed if it saves time and provides a solid ROI within a defined time span -- typically two years. That's assuming you don't lose anything with the upgrade or have to call in the forklift operator.

Enterprise PACS

PACS has changed, but it's definitely not dead. Where do we go from here? It's all about the enterprise.

An enterprise PACS varies from a "regular" PACS on two fronts: interconnectivity and interoperability. For years, PACS worked fine as a standalone solution for the radiology department. Radiology studies need to be shared everywhere, however, to realize their full value. Although CDs once allowed patients to bring images to the physician's office to be viewed, these have been supplanted by image-sharing software that sends images and reports directly to a physician's office or even their cellphone in seconds.

There is also a movement as part of healthcare reform to provide individuals with easy access to their health information. Several companies have developed "patient-engagement" software applications that allow patients to get their healthcare information electronically, although few systems currently allow the sharing of radiology and cardiology images.

Unlike conventional patient-record portals where only 20% of medical records data are available online, patient-engagement software allows both the patient and clinician to obtain an up-to-date overview of the patient's entire medical history. This requires the vendors to interface to the hospital's EHR system using industry standards that support the electronic exchange of healthcare information.

The Fast Healthcare Interoperability Resources (FHIR) standard does this best, but sadly, fewer than 5% of all hospitals in the U.S. currently support it. Widespread national and international usage of FHIR is expected to grow exponentially in the new few years, however, as many vendors are stepping up to the plate to support this.

Just as image-sharing software lowers the cost of providing a patient's study from approximately $15 per CD -- factoring in all associated costs -- to just pennies, patient-engagement software also significantly reduces costs to provide patient data at both the hospital and patient levels.

Patients requesting digital copies of their health records -- including medical imaging studies -- can be charged up to $6.50 per request or more, as long as the costs are reasonable and are permitted by government regulations. Using patient-engagement software that integrates information from the PACS into the patient's EHR, a hospital or imaging center can provide unlimited access to the patient's entire record for a full year at a fraction of the cost of that single request for a record. The data are then made available freely to the patient and his or her healthcare providers.

Past prognostications

It's fun to read the prognostications of years past, like "2015: Department-owned RIS turned off" and "2016: Department speech recognition systems turned off." It's even more fun reading about past projections of PACS archives being turned off and legacy data migrated to a VNA and modalities disconnected from PACS the two years following. Any vendor selling a RIS in today's marketplace -- and not just vendors who offer RIS functionality as part of an EHR -- will tell you there has been a resurgence in interest in RIS, and that business is stronger now than it ever was.

The same can be said about speech recognition systems, although, in fairness, I have seen several other clinical departments piggyback on the use of speech recognition software purchased by the radiology department. After all, expanding the speech recognition system makes a whole lot more sense than buying a completely new system for another department.

Legacy data migration to the VNA alone can take years and cost a bunch depending on how the previous image data was stored. Lastly, pathology PACS is in its infancy and still has a lot of acceptance and cost barriers that have yet to be overcome.

Winners and losers

As far as who will live and die in this marketplace, the most accurate prediction seems to be that only those who are "highly efficient" will survive. Interestingly, though, this statement does not seem to pertain to most major vendors, whose market share has slipped in recent years and whose products have slipped even more.

PACS is becoming more and more the domain of the independent PACS companies that can offer faster, better, and cheaper products than the luxury liners of years past. The market has also come to realize that there is no more safety in going with a larger vendor than a smaller one, and that lower fixed and operating costs, quicker adoption of standards, and the integration of newer products to help increase revenue are the name of the game regardless of who they come from.

So what's the takeaway from reading about the demise of PACS? Leave the fortune telling to Edgar Cayce, Jean Dixon, Nostradamus, or even Carnac the Magnificent. I would love to predict how artificial intelligence (AI), blockchain, fully integrated clinical systems, or any number of other technological breakthroughs will affect PACS or even healthcare in general. But I'm a realist, and there are simply too many variables outside of anyone's control to determine how and when these will have an effect.

It is also neither safe nor smart to try to predict which vendor will live and die in the marketplace. I have witnessed so many good independent companies that had survived and even thrived, only to be bought by a major company and then kept on life support or allowed to die.

The reasons for this could be the subject of an entire article, but mainly it's the result of trying to make a great product better by having it conform to "bigboxitis." In nearly every case, this kills any chance the product has of continuing to grow, and in doing so it takes with it the heart and soul of the people who developed it and made it great.

PACS is not solely about technology. It is about the application of technology to solve problems and improve productivity. The problem PACS faces is that these challenges continue to change and be moving targets. Solutions sometimes take so long to implement that when a fix is finally brought to market, the problem has ceased to exist and is supplanted by a newer problem. Fast fixes are a must.

But know this. PACS will always be a part of the solution, whatever form it takes and will never, ever die. You can take it to heart, too, because I heard it from Nostradamus in a dream just last night.

Michael J. Cannavo is known industry-wide as the PACSman. After several decades as an independent PACS consultant, he worked as both a strategic accounts manager and solutions architect with two major PACS vendors. 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, contract reviews, and other areas. The PACSman is also working with imaging and IT vendors developing market-focused messaging as well as sales training programs. He can be reached at [email protected] or by phone at 407-359-0191.

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

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