Yours is a multisite hospital system or a large radiology group with a
growing network of referring physicians. You would like to grow your
business amid intense competition. How can your new picture archive and
communications system (PACS) help make a difference?Which vendor offers
the fairest contract terms and will support you over the long haul?
Whose implementation is the smoothest?
Many hospitals and
radiology practices are asking these questions as they prepare to swap
out their old PACS for a new one. In fact, a recent study found 21% of
hospitals based in the United States (U.S.) plan to replace their
Yet in the era of anytime, anywhere
health care, when speed and efficient delivery of service are paramount,
what should today’s PACSlook like? To answer that question, first
envision a PACS ecosystem that extends well beyond radiology. Next,
search for a PACS that helps improve productivity through useful
features and functionality, accessibility, and scalability. Consider
compatibility with existing IT solutions, in particular with electronic
health records (EHR). Then devise a data migration plan and test
integration. Finally, measure productivity to determine your
Functionality key to success
the goal of implementing a new PACS is to enhance productivity and grow
your business, then functionality is mission critical.
PACS presents the opportunity to rethink your entire imaging strategy
and identify the features and functionality that will enhance workflow
and productivity as well as services to referring physicians. “The top
priority—you want to get a PACS that your radiologists are going to like
using,” said Gary Danton, Chief of Imaging Informatics for the
Department of Radiology, University of Miami (Miami, FL). When the
University of Miami acquired its namesake hospital and integrated it
with the remainder of the UHealth system, a single PACS was needed for
the large multisite hospital network.
Radiologists wanted an
easy-to-use and complete platform to drive their specific workflow. Many
of the hospitals in the network were already using Philips iSite PACS.
“We wanted a PACS that could facilitate our workflow. We are integrating
all sections of radiology, and we needed to divide the studies into
worklists based on who was going to be reading what kind of study,” Dr.
The radiologists also looked for a solution with
workflow tools to facilitate daily work, including peer review,
critical findings, communication between radiologists, and a single
log-on enterprise solution.
“The new PACS has streamlined the
daily workflow, and because the PACS is now unified, when you go through
the different facilities,you are looking at the same dataset, making
the process more efficient and consistent,” said Russell Kuker, MD,
Diagnostic Radiologist,University of Miami.
feature was the ability to view images on mobile devices. “Now
radiologists want to be able to review a study remotely. If a
radiologist is on call, he or she can do a preliminary read on an iPad,”
Dr. Danton noted.
When Siddharth Prakash, MD, DABR, Vanguard
Medical Imaging P.C. (Melville, NY), was evaluating different PACS for
his imaging center, he needed to make sure the patient’s medical data
was archived properly and that he could interpret them and send the
reports to the physicians at a relatively inexpensive cost. “I was
looking for a PACS provider that was looking into the future and trying
to incorporate other devices, such as iPads and smart phones, and a
simple system for contacting referring doctors,” said Dr. Prakash. “Most
vendors are focused on PACS interface issues, but most PACS interfaces
are the same. So I wanted to find a solution that was taking the next
Efficient communication with referring
physicians is an integral part of the competitive strategy at Vanguard
Medical Imaging, where they use Brit’s Roentgen Works system. “More
doctors want to see reports on their mobile devices, and when we provide
this, they remember that my practice was able to do that while others
were not,” said Dr. Prakash.
“I like Roentgen Works because after
dictating a case with a microphone, you can call a phone number and
relay the results to the physician. They have an urgent-callback system.
The fact that it tells you there’s an urgent finding is great,” he
Radiologists at Hill Medical (Glendora, CA) had their eyes
on a PACS with several new features they thought would enhance report
quality and productivity. According to Jon Foran, MD, a radiologist at
Hill, some of the key features included a unified worklist to display
images from multiple PACS on a single viewer, a system capable of
prefetching images outside of the facility, and merging priors in a
federated worklist in order to see relevant priors regardless of where
they are generated.
“We were looking for a PACS with
critical-results automation, and peer review beyond 2% compliance with
quality metrics; in other words, utilizing shared PACS text messaging
capabilities. We wanted unsigned preliminaries to be immediately
available to the EHR and eliminate hand-written prelims and faxes. We
wanted to copy and paste exam data from the RIS. We needed to share
folders for tumorboard, and, finally, we wanted advanced 3D on our
PACS,” indicated Dr. Foran.
They adopted Merge PACS, which
provides a fully integrated workstation with 3D, mammography, and
PET/CT/MR/nuclear medicine fusion, that is web-based to enable access to
images regardless of the referring physician’s physical location. The
platform also offers long-term storage with iConnect Enterprise Archive
Meanwhile, as Rays (Littleton, CO) teleradiology
services continued to expand, so did the need for a more efficient and
flexible PACS.The group recently selected Visage Imaging’s Visage 7
platform as its new PACS, in part due to Visage’s patented streaming
technology,which rapidly displays current and prior studies of nearly
any size, over minimal bandwidth. According to Ted Tzeng, VP of
Technology at Rays, “Basically, with the reduction of data transfer
requirements on our infrastructure, the scalability of our
infrastructure is improved.”
“You do not have significant wait
times for images,” Greg Rose, MD, PhD, President and CEO of Rays, went
on to explain. “It beats the usual DICOM pull or prefetch technology,
and it works well with our workflow.”
For Meadville Medical Center
(Pennsylvania, PA), efficiency was a challenge because its previous
PACS could not transmit images directly out for its teleradiology
services. This basic task required using a separate workstation. To
resolve this issue, Meadville adopted Opal RadPACS by Viztek (Figure 1).
As a thin-client, it has a small Web install, allowing physicians to
view images from virtually anywhere. “It essentially doubled the amount
of time to do that transaction,” said John Wilpula, PACS administrator,
Meadville Medical Center. “Now we are rolling out the new PACS to
physician offices, so they can log onto the same PACS and look into the
Connecting to EHRs
Replacing a PACS
presents an opportunity to reevaluate current and future imaging needs,
both within the radiology department and across the health care
Today, providers need to determine how
well a PACS works with their existing EHR. To support interoperability,
consider implementing a vendor-agnostic content storage platform or an
enterprise viewer to allow referring physicians to access images.
the last several years, the Integrating the Healthcare Enterprise (IHE)
initiative has made significant strides in driving the adoption of
standards in health care IT, in order to accelerate the use of EHRs and
improve the exchange of information among healthcare systems.3 However,
a 2011 study by KLAS indicated interoperability between PACS and EHRs
continued to pose problems. Some EHRs integrate more easily with certain
types of PACS; for example, Allscripts EHR reportedly is easily
integrated with Sectra PACS; Cerner’s EHR withFuji PACS; and Epic tends
to integrate very easily with McKesson and Philips’ PACS. Therefore, the
CIO needs to identify the level of interoperability of a potential new
PACS with its existing and/or future IT infrastructure.4
integration was of the utmost importance when the UHealth system
unified its hospital network on Philips’ iSite PACS version3.6, and
because it has plans to adopt Philips’ Intellispace PACS 4.4 next year.
This means patients can undergo an imaging exam at any hospital in the
health care system because all of the images are stored in one PACS. For
referring physicians in consult with a patient, there is a single login
to access all patient records and imaging exams.
should be able to open up a study directly from the EHR; ideally in a
viewer that has all of the functionality that they would have as if they
were in a PACS. That’s why you want a complete enterprise system, and
you want it to integrate with your EHR,” said Dr.Danton.
Joaquin General Hospital (Stockton, CA) recently implemented
Carestream’s Vue Motion, which links the PACS to the hospital EHR.The
unified image viewer resides on a server that supports a variety of
access methods to view PACS images as an HTML5 browser page.
are moving into a period of competition, which means you not only need
to meet your own needs but those of an external partner’s, or you’re not
going to get those referrals,” indicated Don Johnston, CIO, San Joaquin
General Hospital.“Right now, our concerns are on functionality and
distributing those images, and we have chosen to look at EHR products
that recall the image from the PACS; they don’t store the images. That
was one of the attractions of Vue Motion—essentially it is EHR agnostic.
We want to stick with an HTML5 presentation product that doesn’t
require a dedicated viewer in order to get to the PACS,”said Johnston.
added, “Vue Motion lets outside clients look at PACS images and
reports. We bring the images into our own PACS for reading by
radiologists. When our providers come in through our EHR and look at
studies, the EHR launches Vue Motion so they can see the images.”
to the latest rules set by the EHR Incentive Program, commonly referred
to as Meaningful Use (MU), images stored in a PACSor imaging archive
will need to be accessible for viewing in an EHR environment.
Johnston’s team, integrating the image viewer to link the PACS with the
hospital EHR was necessary for meeting the MU criteria.“Some of the
latter stages of MU require exchanging meaningful information with other
entities. Vue Motion allows us to tie into the privacy rules from the
EHR so we are properly segmenting data that is based on the relationship
a physician has to a patient. So this workflow will support some of the
elements of stage 2 and 3 of MU,” he said.
Security is another
important consideration. With Vue Motion, the system enforces HIPAA
patient privacy laws because, once the provider views a patient’s data,
the client restricts the provider from accessing a set of images for
another patient without having proper permissions. As Johnston explains,
Vue Motion is called through the browser so that the EHR is enforcing
the HIPAA compliance rules.
Similarly, at Meadville Medical
Center, the replacement PACS was integrated with an EHR and images are
accessed on a single viewer across the platform. “The EHR connectivity
was an important consideration because it is required for MU. As far as
the future is concerned,there would be no point in exploring a PACS if
it couldn’t integrate with an EHR.”
Data migration and integration
data from legacy systems is an important milestone in the PACS
replacement process. Specific challenges in database migration may
include patient reconciliation, interfacing with existing IT systems,
proprietary file formats, and the actual data migration itself.
integrating the PACS with existing IT, best practices for managing the
process include: documenting the enterprise workflow in detail, using
standards-based integration, running workflow tests in an integrated
test environment, and working with vendors to make changes on all
integrated systems (Table 1).
Before getting started, however, it
is a good idea to anticipate potential problems. Ask key questions, such
as: Is there data from other hospitals? Is a RIS feeding the
information? Is there old data and has it been through previous
migrations? Which data needs to be migrated? Are all data types
supported in the new system; eg, structured reports, word documents,
PDF, RTF, and so on?5 At Hill Medical, the IT team hit a
roadblock when it began migrating images and scanned documents.
“Although the reports were already in our RIS, the scan docs were a bit
of a headache to transfer. We found a third party that migrated the
images and scanned docs in one operation – that was the most economical
solution,” Dr. Foran indicated.
Over the next 6 months, PACS
administrators at Hill Medical expect to retire old and duplicate
viewing workstations for hospital and outpatient PACS, comply with PQRS,
and at the same time boost productivity and reduce costs.
the PACS administrators at Meadville Medical Center had to jump several
hurdles in their first phase. “We initially had to overcome challenges
with integrating modality worklists and several different modalities,”
said Wilpula. “But we have since worked through most of those issues.”
common and costly problem is system downtime. With most PACS, there are
bugs to work out in the initial integration phase, and thiscan cause
burdensome and costly downtime. Yet there are several different
strategies to ensuring total uptime.
At The Doctors Clinic
(Silverdale, WA), they decided to migrate data nightly. “We began
migration at the time of go live. We migrate nightly and have completed
about 90% in the 9 months we’ve been live,” said Brennan Dobbins, Clinical and Ancillary Services Director atThe Doctors Clinic (Silverdale, WA).
Clinic is part of Northwest ImageShare (NWImage), a collaboration of
multiple imaging centers on a cloud-based regional imaging management
platform, consisting of one data center and one image archive that they
“At implementation, we began a query and retrieve
process at the scheduling and technician level for comparison to check
if any patientstudies have not been migrated,” said Dobbins. “In the
NWImage environment, Harrison Medical Center monitors the process and
sends us reports on the number of studies moved. Then we clean up the
mismatched RIS on our side of Sectra PACS.” This phased approach has
proven very effective, says Dobbins.
Another phased approach is
one Philips Healthcare prescribes. Under their process, first, the image
data is copied as it’s generated, then the data is archived in both an
existing system and in the Philips iVault archive. The next step is to
integrate iSite Enterprise to distribute images and reports from the
radiology department to referring physicians sites. Once the current
PACS contract expires, the department can move forward with adopting the
iSite Radiology module, an open-platform, scalable radiology reading
software, to complete the iSite PACS.
While the UHealth system
implemented a Philips PACS, they developed a step-by-step data migration
suited to their particular workflow needs. “We were willing to go live
with 3 months of data transferred, before completing the migration on a
year-by-year basis,” said Dr. Danton.“This strategy was discussed at
SIIM. Transfer most of your comparisons from the past 3 months, and then
if you need a study that is older than that, you can still do a query
Measuring ROI on a PACS
several key factors to look at to determine whether a new PACS is worth
the investment. These include the PACS solution’s uptime; ability to
scale; interoperability; frequency, complexity and cost of upgrades; and
the vendor’s approach to training and support. Some of these factors
are measured over the lifetime of the PACS, while others, like
efficiency, productivity, and cost savings, are more readily apparent.
Rays, gains in efficiency are monitored and factored into ROI. For
example, the ratio of ‘sends’ per study actually reversed. The previous
PACS required sending a study to 10 different locations, some of which
were outside of their network. With the new system, customers send
multiple studies to a single server in the data send, requiring just a
single send to forward.
“When you evaluate the cost of a viewer,
it helps to use real data and include soft elements,” said Dr. Rose.
“When the improvements inefficiency, ease of use, and error reduction
outweigh the added cost, you are saving money.”
Efficiency is not the only measure of ROI; increased productivity also correlates to ROI.
leads to the expansion of our business, which can be considered ROI. We
have been able to change the delivery model,thanks to the adoption of
Visage PACS,” indicated Tzeng. “We’re no longer concerned with the
location and bandwidth limitations of radiologists, enabling them to
read from anywhere.”
Since The Doctors Clinic integrated Sectra
PACS on the NWImage platform, it has seen tremendous improvement in
productivity, patient care, and physician satisfaction, according to
“Sectra’s superb worklist flexibility has streamlined our
workflow for moving overflow studies to our outside contractor. Our
referring physicians and radiologists are able to see all patient
studies regardless of which local imaging center or hospital they we
imaged in. This eliminates multiple sign on, passwords, and PACS
software interfaces on physician desktops. We also have reduced our PACS
and support costs by 60%,” said Dobbins.
Cutting additional costs
adds to the ROI tally. At Meadville Medical Center, they needed a more
robust solution for backup and disaster recovery, but didn’t want to pay
for more plug-ins. “With the previous PACS, there were several add ons,
requiring additional licensing fees.
It made more economic sense
to upgrade the entire PACS rather than to add a second PACS backup and
disaster recovery,” said Wilpula.
Fortunately, backup and disaster
recovery, a mammography and PET/CT interface, and a dictation and
transcription solution came standard with Viztek’s Opal Rad PACS. “Now,
we are utilizing the dictation and transcription system on the Viztek
PACS—it saved us from investing in a whole new dictation and
transcription system,” said Wilpula.
Means to a better end
economic pressures place greater demands on radiologists to produce,
the search for a game-changing PACS can seem overwhelming.
important to remember that replacing a PACS is an opportunity to develop
a more effective and competitive image-management strategy. Construct a
PACS ecosystem that extends well beyond radiology, accessible on the
enterprise level and remotely. Look for a thin client or cloud-based
solution that provides a robust toolset both natively or remotely; one
that is mobile friendly; doesn’t require endless plug-ins; yet is
scalable with minimal cost. Today’s PACS must be interoperable with
EHRs, image viewers, image archives, and other IT applications. Devise a
plan to mitigate downtime during data migration and software
integration, possibly through a phased approach.
signing on the dotted line, or submitting a digital ‘signature,’ seek
out a strategic partnership with a vendor who will support and respond
to your needs during the lifetime of your replacement PACS.
- 2011 U.S. PACS Replacement Study. Capsite. http://capsite.com/news/press-releases/study-21-of-u-s-hospitals-plan-to-replace-their-radiology-pacs-solution/. Accessed July 17, 2013.
- Shrestha RB. Guide to replacement PACS, version 2012. Applied Radiology. 2012;4:36-37.
- About IHE. IHE. http://www.ihe.net/About/. Accessed July 17, 2013.
B. PACS 2011: A victim of its own success. KLAS.
Updated November 23, 2011. Accessed July18, 2013.
Replacement Best Practices. Sectra.
Accessed July 17, 2013.