Dr. Shrestha is the Vice President of Medical Information
Technology, University of Pittsburgh Medical Center, Pittsburgh, PA, and
the Medical Director, Interoperability & Imaging Informatics,
Let’s start with a bit of a history lesson
around the DICOM standard — the Digital Imaging and Communications in
Medicine standard — that essentially led the way to picture archiving
and communications systems (PACS), from its academic conception all
those years ago. It was back in early 1983 (Pianykh, 2008) that the
ACR-NEMA (American College of Radiologists and the National Electrical
Manufacturers Association) Digital Imaging and Communication Standards
Committee was founded. After 2 years of work, the first version of the
standard, ACR-NEMA 300-1985 (also called ACR-NEMA Version 1.0) was
distributed at the 1985 Radiological Society of North America (RSNA)
annual meeting and published by NEMA. In 1988, ACR-NEMA 300-1988 (or
ACR-NEMA Version 2.0) was published. In 1993, DICOM version 3.0 (also
known as DICOM 3) was released, and is the current standard. Although
the standard itself has not changed, 23 supplements have been added to
address technological changes and needs arising since the original
standard was prepared. These supplements extend the functionality of
DICOM to many types of digital imaging communications.
quick review of the brief history of the DICOM standard above indicates
one thing — PACS has been around now for a while. We saw a large-scale
mass adoption of PACS nationally in the early 2000’s. Today, in 2012, it
is impossible to argue against the logic of implementing PACS, and we
have seen how in the last decade, PACS implementations have reached
almost every nook and corner of imaging centers and hospitals
PACS have matured tremendously, as have the
implementation processes. A walk around any radiology trade show
bedazzles anyone with the sheer number of imaging vendors touting one
system or another, with added features, functions, tools and widgets.
The reality, however, is that radiology workflows as well as the
healthcare organizations have matured, too, over the years. Many who
embraced the digital era in radiology with PACS years ago are going
through various stages of maturity. There is a move towards redefining
the demands of what PACS should deliver. Provider organizations often
struggle with one or more aspects of their current PACS system, and for
one reason or another often seek to move on to another vendor. Indeed,
today, the largest growing segment of the PACS market is the replacement
PACS market (Division, 2010).
But what does it mean today to
switch PACS vendors? In this day and age of meaningful use, wide-spread
electronic health record deployments, and competing needs in not just
the imaging department, but across the provider space, there is a
growing redefinition of what enterprise imaging really is, and an
evolving approach to trying to fill the variety of often complex needs
of the radiologists. It is not enough today to simply have a PACS system
that archives studies effectively, and displays them efficiently for
interpretation or review. Our clinical workflows in radiology are more
mature and complex than ever before. Furthermore, our expectations for
system performance, uptime, vendor responsiveness and the spectrum of
workflow-centric tools are varied and many — and growing. It is no
wonder then that every 7 to 10 years, provider organizations raise the
white flag with their existing PACS vendors and look to replace their
systems with something better.
Replacing a PACS is easier said
than done, and this is clearly a decision that no one should take
lightly. Challenges include many, from real workflow concerns for
technologists and radiologists to database migration issues, such as
patient reconciliation, interface issues and hurdles with proprietary
file formats and the actual data migration itself, which could turn out
to be a nightmare.
Implementing a PACS is a major commitment, and
the analogies to marriage are many. So bear with us as we lay a few out
to you. Much like any good marriage, the key is of course to first
marry the right individual (in this case, the right PACS vendor)! But
despite the best intentions, one often gets to the divorce court.
Well-constructed prenups are a great idea (detailed service-level
agreements, with defined expectations and penalties, along with detailed
what-if scenarios and obsolescence protection), but if the unfortunate
need to split comes up, make sure the kids don’t hurt too much (protect
the data first, ensure the workflow continues to be smooth in the
transition for all involved). It’s also highly recommended to go through
focused rounds of serious discussions with your current vendor
(marriage counseling?). Most PACS vendors are at a mature stage and are
at varying stages of adoption of best practices, so a little (or a big)
push may actually yield favorable results.
But if splitsville
comes calling, ensure you hit the dating circuit well ahead of time —
you will need as much time as you can get to plan well and plan
thoroughly. You will need experienced and focused team members to see
beyond the glossy brochures of the next vendor, in this increasingly
genericized imaging market. Ensure you have a lean, focus-oriented yet
well represented steering committee leading the charge and handling all
aspects of change management.
Work with the right team of
clinical, IT, finance, supply-chain, business and legal experts to
ensure you leave no stone unturned. You may need a third party to assist
in the data migration process. Ensure that you have a strong QA
methodology in place to ensure the accuracy of the migration, and the
mapping of a number of possibly idiosyncratic yet critical fields such
as annotations, measurements, tables and pointers. Build
well-thought-through contingency plans. Evaluate the evolving role of
ancillary systems, such as the radiology information system (RIS),
dictation system, advanced visualization, and image-postprocessing (eg,
computer-aided detection (CAD), lesion management software, etc. The
tide today is turning towards a more patient-centric workspace that is
much less siloed and much more workflow centric and tied tightly
upstream to the electronic medical records (EMR) (CPOE, decision
support, enterprise access).
It is highly recommended to use this
as an opportunity to reevaluate your current and future imaging needs,
both within the radiology department and across the healthcare
enterprise. An actual PACS replacement is not the only way to do this,
but this is as good an opportunity as any to put a strategic focus on
rearchitecting the infrastructure, embracing a more vendor-agnostic
content storage paradigm (that includes DICOM, as well as non-DICOM
content such as waveforms, movies, sound, stills, etc.) that accounts
for specific workflow needs beyond radiology.
In this era of
meaningful use and patient-centered care, an enterprise imaging strategy
that accounts for current and future digital imaging needs across
specialty areas, enabling easy image and content sharing, and ease of
workflow will be highly regarded.
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