AuntMinnie.com · The PACSMan Pontificates, Episode 2 - RFPs
The early 1990s were technically considered the start of semi-real PACS, even though some of what vendors called PACS in the mid 80s was far from it. Big companies like GE/IBM with their Integrated Diagnostics product, AT&T and Philips with their Commview offering, Siemens with Sienet, and others took the world by storm offering their version of PACS that looked great on paper.
After all, how could you go wrong buying from the big boys? Um … very easily. In a nutshell the technology simply wasn’t there yet. but the marketing sure was. More plainly put, the reality was that some of the PACS offerings served better as an artificial reef off Connecticut, where many components reside even today, than in the hospital setting they were destined for.
After all doesn’t everyone need a custom-built, all-metal dual screen stand-up viewing station that's shell-painted battleship gray, imported directly from England at a cost to the vendor of $20K each so that primary care physicians could see images on the floor? Of course!
The truth was most PCPs couldn't care less about the images, let alone the findings and impressions they could (maybe) get from the RIS. With the exception of specialized areas like surgery, orthopedics, oncology, and others, this statement holds true even today. It also showed the highest level of understanding that existing with the big boys.
Their “we know what is best for them” statement showed how much they understood the needs of the radiologists and clinicians … which is to say next to none. I worked for one of the big boys for a few years, although my honesty was my ultimate downfall. When marketing told me “You make the sale … we’ll worry about making it work," I knew my time had come to play the Wiz and ease on down the road. I felt so good faxing in my letter of resignation knowing I was playing Spike Lee and doing the right thing ... until a few days later when reality hit and I realized I had no income, no company car, no insurance … nada.
OMG -- what have I done! That was the start of my PACS consulting life. I knew enough to be dangerous but that was OK because back then few others in the marketplace knew any more. I also had some amazing mentors like Dr. Sam Dwyer who schooled me not just on PACS but on life itself as well. I can only hope that, before I die, I have some vestige of a relationship like he and his wife Mary Lou did …
There were several big-name facilities we heard from back in the day who believed the marketing claims and wanted the latest and greatest solution. No more film!!! Life is good!!! Nice try. Since they wanted it and I couldn’t talk them out of it, I developed a Request or Proposal, better known as an RFP, to help evaluate vendor offerings.
New standards
Both DICOM and HL7 standards weren’t even developed until the early 1990s and it took over 10 years before these “standards” were even marginally adopted by most vendors. Every PACS and modality vendor had their own DICOM conformance statement, which amazed me. How it could be called a standard when you had to show how you adhered to it? That’s like two people interpreting their marital vows in different ways … no wait, that happens now. Never mind.
As far as standards go, there are hundreds of internal file formats (IFF) like JPEG, GIF, and PNG, yet when you clicked on a photo with one of those file extensions it magically appeared. No one knew or needed to know what IFF it was. With DICOM, you needed to read the King James Bible to understand what was and was not supported by the vendor and the modality manufacturer too. Objects, service classes, tags (regular and private both), profiles, fields, and elements were all parts and parcel of DICOM. God forbid you don’t know it all. What was standard was the easy part, but everything was supported differently by each vendor.
Until more widespread use of the new industry standards took place in the early 2000s, you had to evaluate DICOM conformance statements that read like War and Peace. Ideally, this was data that the RFP often brought to light. Realistically though, even the vendors responding didn’t understand it all.
State of the art
The RFPs described the hospital and its desired connectivity to modalities and the information systems like the RIS (if it wasn’t part of the PACS that is which it often was), a projected way the system should work, the local area network infrastructure -- usually a 4-MB token ring or a screaming 10-MB Ethernet -- and so much more. Things we don’t even consider today were state-of-the-art technology back then, including archiving and using data compression to speed up the transmission process and reduce space in the archive.
Massive 12-inch optical platters that held less than 1 GB and cost nearly $500 each were the norm. Today a flash drive holding a terabyte of data costs is under $50. Most interesting was how little of the RFPs dealt with radiologist needs. Most were purchasing-related details using the same RFP format for hospital linens as they did for PACS.
Thankfully, over time the RFP evolved into a technical spec with more radiology-related data added. What’s the difference? With a tech spec the end user tells the vendor what they want. With an RFP the vendor tells the end user what they have. Huge difference.
The cloud
Today with Cloud solutions a tech spec is all that is required, although several facilities still require an RFP. Why? I’d like to say old habits die hard, but where money is involved -- especially in government facilities or even some not-for-profit entities -- these are still required. Many sites need to show that proper due diligence in the selection process was followed whether the RFP is considered reasonable or not. This also allows a facility to reference the RFP responses in the event the award is contested.
Sadly, this typically adds three to four months to the evaluation process. You have to develop the RFP, submit it to vendors and allow them proper time to respond, and evaluate the responses internally.
Does it help?
In the end does the RFP help define the best vendor? Usually not, although how you define the evaluation criteria makes a huge difference. RFPs used to be all about price. Now it’s primarily about meeting the needs of the radiologist by impacting workflow, improving productivity, etc.
Can an RFP provide that sort of input alone? It can’t. Only scored demos, feedbox from sandbox demos where other rads in the group have access to the software via the Web, and discussions with end users can help evaluate the suitability of the PACS. That is why RFP scoring and even general scoring today is heavily favored towards radiologists.
In many cases, radiologist feedback makes up as much as 50% of the decision weight. Price comes in second but a distant second at 20%, followed by meeting the projected timeline, adherence to the contract terms and conditions, meeting formal acceptance criteria as well as default criteria, training and implementation (which really aren’t major factors in a cloud system), and so many other areas.
It is important to note that a price that is almost 30% higher than the lowest-priced vendor can be easily justified through productivity gains and other means. While the price quoted is still important, its importance is a lot less these days.
Here is another reality. Before a facility goes out looking at replacements for their existing PACS (most have had at least one PACS already, several three or more) they pretty much already know not just what they are looking for in a vendor but also whom they want. Most have done unofficial due diligence at trade shows, website reviews, remote demos, etc., and have had the chance to evaluate what’s out there and narrowed the field down to those they like.
Like dating
Indeed, evaluating vendors is very close to dating today. You look on various websites to see who (or) what is out there, then swipe right for those who look interesting to you and swipe left for those you aren’t, just like it happens on Tinder, Bumble, OK Cupid, and others.
This typically narrows the field from 40 or so vendors to about half that number, tantamount to looking over people you may be interested in at a bar and only focusing on those who meet your “preliminary requirements." You then look at the websites, Facebook accounts, LinkedIn, and other web-based resources to see what things you can uncover about the vendor. That typically narrows the field even more.
You then contact the vendor and have some preliminary discussions. Keep in mind that up until now it’s just been phone calls or text messages -- nothing in person. You can also tell a lot by how responsive a vendor is by the time it takes them to return texts and emails and by what they share. By the time you get to text messaging and emails, now it’s time for the initial phone call.
This is the tricky part because everyone on the end-user side of the organization may have different questions. Answering everyone’s questions comes later. For now, it’s all about general stuff, mainly who has the system that is of comparable size to you and their thoughts on it. Again, the dating equivalent is what do you like to do for fun and where do you like to go.
The first date
When you get done with all the preliminaries now it’s time for either a lengthy phone call or an on-site meeting -- the first “date,” if you will. You can spend a fortune trying to make an impression that ends up with nothing but costing you money. But in the end its worth it. I tend to take the cheap approach and meet at Steak ‘n Shake during happy hour, minimizing any losses from both a time and financial standpoint while still getting a halfway decent meal.
Now you can call me the cheap bastard I am but hey, it’s pragmatic. The ambiance isn’t the best but you are there to talk, not deal with listening to strolling violinists. If you are fairly confident that you want to spend more time with the vendors to know more about them, you can splurge a bit and go to Olive Garden or any one of the major chain restaurants … but no Ruth’s Chris Steak House this early on.
Using a sandbox
If you like what you see or hear, then its time to introduce the person you met to your friends. That is called using a sandbox, where the other rads in the group can have access to the software remotely for a week or so and provide their feedback. Not every group uses these successfully, but if even half of them provide you feedback on the software, then it’s a success.
This again is the equivalent of your friends meeting you and your newfound friend at the bar again and all of you spending a bit of time together. Now I’m a bit old for in-person meetings with my friends, but over the years have become a pretty decent judge of character.
That said, I at least chat with my friends about them. I also acknowledge that while I’m not Richard Gere I’m not Bad Bunny either. Anyone who wants Bad Bunny at my age is also not a good fit. Laugh. That hasn’t keep me from spending time early on years back uncovering entitlement queens or pillow princesses but I’m really good at cutting my losses early on now too.
Proper due diligence
By now you probably have the list down to three, with one vendor considered a primary and the others there for “discussion purposes.” Doing proper due diligence takes time, especially in evolving markets like Cloud computing. This is the equivalent of finding out even more about your date -- likes, dislikes, must haves, like to haves, things that are a turn-off (and turn-ons if you are bold enough to ask) , expansion capability (what he/she is looking for, not their waistline), etc.
This is especially important if he/she is either newly single or has been available for a while but never seems selected to go out more than a few times with any one person. Knowing the answers or even just suspecting why based on actions and interactions experience is important. By the end of all that you pretty much confirm that the person you have been looking at the past month or so checks off most of your boxes and you wish to go further. Just don’t ask for redundancy or backup in a relationship or you’ll be back at the bar again …
Not many facilities do site visits any more due to cost and time but most do at least a phone call to their counterparts. It also levels the playing field with the modality vendors who used to offer to fly a client halfway around the world to see a system there when there was one 50 miles up the road. This hasn’t happened very often in the past decade or so, but it used to be the methodology of the big boys when someone was looking at CT, MRI, and other imaging modalities in the past … and PACS was on the menu as well.
Closing the deal
In the end, you continue your due diligence by learning all you can before you bring it to legal to handle the contract issues. This can about as lengthy as some engagement periods but contracting is crucial. There are no pre-nups with PACS, so what you get is what you get; you have to make the best of it. Thankfully, with PACS there are upgrades and updates to look forward to. If you are lucky you get the same benefits out a relationship too.
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.
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 to develop 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 AuntMinnie.com.
