Enterprise PACS: Practical, Proven, and In Demand
Information Systems at Every Turn
In today's dynamic health care environment, providers are facing significant pressure to provide timely, secure information access to all segments of the enterprise. Wireless computing, tablet PCs, electronic medical records (EMRs), automated pharmacy applications, information systems (hospital, radiology, laboratory, and surgery), and physician order entry systems have been implemented across institutions of every shape and size — community, academic, and tertiary care facility alike — all intended to aid in patient care while reducing the spread of medical errors.
In addition to results data from radiology, laboratory, and pharmacy, increasingly institutions have focused on providing true integrated services beyond the confines of individual departments. Stovepipe systems are effective, but once practitioners become accustomed to incremental information access, their next logical desire is for sources of information to come together, to present a cohesive view of patient care. And without diagnostic images, these systems remain only partially successful, because they represent only a fractional view of the electronic patient record.
Ubiquitous Imaging Demands
Within the health care continuum, diagnostic imaging services represent perhaps the most definitive step of the care process, leading to quick diagnosis and effective treatment options. The technologies comprising the imaging modalities of computed tomography (CT), magnetic resonance imaging (MRI), mammography, positron emission tomography (PET), nuclear medicine, and ultrasound all have provided vast benefits to patients and clinicians. Most importantly, recent advances in imaging modalities have spawned a revolution in unique applications powered by digital innovations and the fusion of traditional modalities.
For example, modern medicine today uses super-fast, multi-slice CT, integrated PET/CT scanners, interventional MRs, digital angiography, digital mammography, computer aided diagnosis (CAD), and computed/digital radiography. External to diagnostic imaging, imaging applications continue to expand in their scope and breadth, such as cardiac applications (cardiac catheterization, echocardiography), pathology, image-guided surgery, and radiation therapy. Image fusion, 3-D, functional imaging, and reconstruction workstations are becoming vital in nearly all clinical settings. Imaging workstations are appearing in the operating room and in the referring physician's office.
These modalities, methods, and workstations are transforming the way doctors collaborate, consult, and diagnose their cases, as well as how they communicate treatment plans with their patients. In all capacities, images are moving closer to becoming an essential part of the physical exam.
But with all of these modern modalities and imaging applications, how can institutions effectively manage the manual distribution, transport, storage, security, quality, and access to images? The short answer is, it can't be done in any practical capacity. Manual, hardcopy images simply cannot be effectively managed based upon the reality of today's clinical environment. Imaging demands are everywhere and have transformed the fundamental manner in which patient care is practiced.
For example, multi-slice CT produces up to a thousand slices for a whole-body exam. That equates to hundreds of expensive hardcopy films that would need to be printed, transported, and so on. The only true alternative to dealing with modern medicine's diagnostic imaging demands is through the enterprise implementation of Picture Archiving and Communication Systems (PACS). Just as the typewriter succumbed to the PC, X-ray film is similarly going the way of the dinosaur. Indeed, many argue that extending access to images and reports via PACS are an emerging standard of care.
It's All About the PACS
Frost & Sullivan recently reported that of all provider organizations greater than 500 beds, 93 percent had implemented PACS.1 This means the majority of academic, tertiary care facilities have realized PACS are necessity for patient care. When considering all institutions in the United States and Canada, Frost & Sullivan estimates a PACS market penetration of 14.7 percent, representing nearly twice as many PACS installations than were present in 1998. But if modern imaging modalities demand the use of PACS, why has penetration been so limited in institutions below 500 beds?
The only practical answer lies in the perceived barriers to entry. Until recently, PACS were regarded as the single most expensive information system, for many reasons. First, institutions historically needed dedicated networks; expensive and specialized technical staff to run disparate PACS databases, archives, and operating systems; and perhaps most importantly, large sums of capital to even consider bringing PACS to their institution. Historically, PACS have been a multimillion-dollar expenditure, which required significant investment in both capital and human resources. Because of this, many early-adopter PACS institutions did so in a phased implementation, resulting in numerous flavors of PACS installations pushing out return on investment (ROI). But chief financial officers demand systems that yield quick ROI, and PACS have always been viewed at best as a cost-neutral investment, or at worst a five-year-plus ROI. This is because even after the initial investment, the significant out-year maintenance expense has been difficult to overcome, even with the substantial soft and hard savings attributable to PACS, including:
- Increased departmental productivity and competitiveness
- Reduced and/or optimized staffing
- Increased speed and HIPAA-secure exam access across the enterprise
- Reduced report turnaround time
- Integrated legacy information systems (HIS/RIS/EMR)
- Minimized film use across the enterprise
- Eliminated use of development chemicals (for traditional X-ray) resulting
in environmental benefits
- Reduced patient exposure by eliminating re-exams
- Eliminated lost films
- Eliminated patient transport due to lack of timely interpretation
- Increased recruitment efforts, while minimizing radiologist and technologist
attrition
- Increased access to subspecialty interpretation
- Enhanced patient care
But times have changed significantly from the early days of PACS. The overall PACS marketplace has seen tremendous consolidation between traditional information system vendors, modality vendors, film vendors, and technology vendors all interested in moving into PACS. Imaging modality vendors have embraced widespread, accepted standards such as Digital Imaging and Communications in Medicine (DICOM); HL7; Integrating the Healthcare Enterprise (IHE); and JPEG 2000 for wavelet image compression.
Simultaneously, institutions have upgraded their networks for shared local-/wide-area bandwidth, archive storage is dropping in cost per gigabyte, and the power of PC computing continues to increase as costs per unit decline. The Web has also afforded PACS vendors a virtual playground for expansion, extending image access to all enterprise imaging stakeholders while developing on an architectural platform that scales significantly more than PACS from the days of old. Increasingly, the most customer-focused PACS vendors are adopting software-based, hardware-vendor-neutral approaches to allow customers the ability to purchase PACS commodity hardware on their own terms, from vendors they prefer doing business with.
These savings combined with other reduced barriers to entry, the increasing prevalence of modern imaging modalities (even at community hospitals), and the growing demand for radiologists and technologists, who are in short supply nationwide, have all worked to prime the pump for institutions seeking PACS implementations (see Figure 1).
Figure 1: Enterprise PACS Economics — Accelerated ROI
While traditional PACS provided significant benefits to patient care, it somewhat restricted the business of radiology by tying up radiology budgets for years following the initial PACS capital outlay. The most attractive PACS vendors offer affordable packages for institutions to implement a more complete PACS, enabling faster ROI with greater probability. A more complete PACS typically includes optimal network infrastructure, computed/digital radiography (to capture general diagnostic exams), voice recognition, softcopy reading-area renovations, use of consultants, effective marketing, and adequate technical staffing. These modern PACS solutions enable the business of radiology to not only accelerate PACS ROI, but also free up capital resources for other business demands, such as new/replacement imaging modalities, facility modifications, staff recruitment, and construction of outpatient imaging/surgery centers.
Optimal Enterprise PACS for All Enterprises
Although no singular definition of PACS exists, the following statement can approximate a working definition of PACS:
"PACS is an enabling combination of technology (hardware, software, and communications systems), integration, workflow transformation, and cultural change in the perception, manifestation, and delivery of radiology services."
By virtue of this statement, PACS are viewed by many as a daunting, if not challenging task. In contrast, PACS have been successfully implemented by thousands of institutions, all with wide ranging capabilities, but clearly all PACS solutions are not created equal. Institutions seeking enterprise PACS solutions must be ever mindful of the following five facets that are critical to PACS selection.
Workflow Matters
If patient care is a workflow combining human and technical systems, then radiology has seen two generational changes in the past five years. Five years ago, workflow was structured around paper requisitions, radiology file cards, and film jackets. Workflow was completely controlled by people. Administrative front-office clerks, technologists, film librarians, and medical secretaries would key, print, sort, label, file, hang, and pull paper and film jackets to control departmental workflow and patient throughput. Physicians could monitor the process simply by looking at the stack of requisitions in their inbox or the stack of film jackets next to the light box (film viewer/alternator). Human error would typically result in lost or mislabeled films, but human systems had evolved to deal with these errors and other exceptions.
Then, the first generation of integrated computerized medical records arrived on the health care scene. Hospital and radiology information systems (HIS/RIS), and EMR systems started to interface with each other and, ultimately, with PACS. Today's modern workflow is the age of HL7, DICOM Modality Worklist, and IHE. This represents an opportunity for software and IT vendors to engineer new systems and to charge a premium to customize and re-engineer the old-fashioned workflow, managed by old-fashioned intelligent beings. Unfortunately, a simple mouse-click error or routine technical problem that could previously be easily spotted by humans are now magnified by the mechanistic file-and-forget approach of enthusiastic integrated systems. All of today's current workflow tools are not equivalent.
Physician adoption of these integrated workflow novelties has been spotty. Security and problems with multiple sign-on requirements led to the invention of Clinical Context Object Workgroup (CCOW) as a human-oriented patch to HL7. Unfortunately, both HL7 and CCOW (which is now a part of HL7) are consensus standards meant to protect the interests of the incumbent software vendors at the expense of physician users. Physicians simply desire single sign-on with the ability to use their image viewer and voice-recognition/dictation system as an integrated pair and with the flexibility to adapt to the dynamic demands of real-world clinical practice.
For the most part, neither referring physicians nor radiologists want an RIS or workflow of any kind. The referring physician wants order status and images to be linked directly to the patient's EMR, and the radiologists would be satisfied with a "next" button on their viewer that is backed up by an equivalent "digital greaseboard" that passively displays how much of what kind of work remains to be performed.
At the end of the day, PACS are not just about replacing film; PACS transform the fundamental manner in which an institution conducts its diagnostic imaging business. The PACS must be an integrated part of the new workflow and, more importantly, a real-time status has to be incorporated into the process. The PACS and new workflow should aim to replace the greaseboard in the emergency room, not just the X-ray film.
Similarly, the ability for radiologists to have their work follow them wherever they travel is of extreme importance. The ability for a radiologist to communicate with other departments and other clinicians as to the status of images and reports is the clinical benefit to both sides of an imaging consultation. No more shoulder-tapping interruption and no more frustrated departments and referring physicians wondering when an imaging exam is in process or finalized. Radiology information systems offer similar workflow and worklist functionality, but these tools are positioned for radiology alone, not for the broader clinician community. The PACS are intended to transform enterprise operations; therefore, enterprise workflow should be optimized as a unique part of the total process.
The Workstation Matters
The ultimate functionality of any PACS and image-management system is visible at the workstation level. The ongoing advances in imaging modalities will continue to create an increasing demand for new and innovative workstation functionality. Radiologists will no longer be the only group that demands particular functionality, and application-specific requirements will exist for all other specialists. An institution should choose to allow access to imaging workstations built on a common user interface, regardless of where the workstation is accessed, to any user, as their location and job description dictates. This provides institutions the ultimate in workstation flexibility, utility, and commonality, and eases system rollout, end-user acceptance, and training.
Standards-Based Integration Matters
In all market verticals, standards have always proven to be the course of least resistance. Whether you are talking about the virtues of VHS or Beta, DVD or DIVX, or DICOM/JPEG 2000 as compared to proprietary streaming algorithms, the choice is clear. In their respective heydays, Beta and DIVX seemed to offer very impressive benefits. But who would want those solutions today, as compared to the standards of VHS and DVD? Similar to X-ray film, these latter technologies have long since expired. In contrast, widely adopted standards afford institutions the greatest flexibility in protecting their long-term investment dollars, as well as their information system investments.
As stated earlier, imaging is converging with all other information systems, especially the EMR. Without standards at the core, integration of images to the EMR becomes extremely cumbersome, technically challenging, expensive, and perhaps unattainable. In contrast, support of standards allows PACS to easily and securely embed images and reports within the EMR for access anywhere within the health care enterprise. Extensive use of standards also allows PACS vendors to stay ahead of the technology-adoption curve by incorporating innovative solutions, perhaps found in niche vendors (for 3-D or orthopedic template tools) or even technologies developed outside of health care, very efficiently and rapidly.
Architectural Scalability Matters
Web-based PACS vendors paved the way, establishing scalability as an issue that is critical to successful enterprise PACS. These Web-based systems have fueled the distribution of images across the health care enterprise, incorporated images into EMRs, processing hundreds of thousands of studies per year for hundreds of concurrent users. While this scalability is not necessary for primary diagnosis by radiologists, scalability for distribution is a requirement for all enterprise PACS. PACS no longer reside in just the radiology department, so images and reports are expected to be readily accessible by all authorized users at all access points within an enterprise. And it's not enough to just be scalable in terms of imaging, because the workflow tools go hand in hand with image access. Accordingly, the "worklist" workflow tools utilized by PACS must be similarly scalable, so PACS access and productivity is not limited for any enterprise imaging stakeholder.
Strategy Matters
As the PACS marketplace matures and stabilizes beyond its original foothold in the radiology department, the real differentiating points become increasingly evident. Almost all vendor selections reveal most vendors can presently deliver adequate, minimal PACS functionality. However, the real challenge for vendors is to package an affordable system that not only meets the needs of diagnostic interpretation, but also addresses the long-term requirements of the larger set of users outside of the radiology department - enterprise imaging stakeholders (clinicians and referring physicians). By providing images and reports to hundreds of users, the most advanced PACS vendors are able to today incorporate the ability of any user to have access to advanced imaging functions, from anywhere, and particularly from within the EMR.
PACS and imaging demands will continue to evolve, with demands for access, integration, and functionality ever-present. Any selected PACS vendor should continue to meet and exceed those requirements, with an architecture and strategy that has the flexibility and foresight to keep ahead of customer demands.
Conclusion
PACS are a transformational technology whose time in the sun clearly has arrived. Prior barriers to entry should no longer be considered as realistic impediments to PACS adoption. This is because institutions of every shape and size, of every care mix and mission, and of every type of financial capacity can no longer afford to delay their PACS investment.
Current PACS solutions exist to accommodate the needs of all environments, with value propositions that not only justify the implementation of PACS based upon the benefits to patient care, but also with the ability to not only gain true financial ROI. Referring physicians are stimulating demand for modern imaging modalities, but they also are demanding timely access to images and reports, based upon their workflow needs. And when modern modalities are adopted through either replacement or new purchases, if PACS are not used to power the new imaging workflow, then the modalities and departmental staff will be performing unproductively. Patient care, enterprise provider relations and institutional investments demand a more productive, impactful approach. That is why PACS are on the budget radar for so many institutions across the country. And when institutions begin to investigate PACS, they need to carefully select their long-term PACS partner based upon selection criteria that considers the importance of workflow, workstation, standards-based integration, architecture, and the overall development strategy of their PACS vendor. None of these attributes should be ignored, so the chosen PACS solution has the greatest potential for short and long-term institutional success.
