During the first ten years of PACS sales, the customer price/performance results were far from optimum. Was this due to manufacturers selling equipment that did not completely meet specifications or perceived specifications? Or was it the result of customers not being willing to change their behavior in order to increase the effectiveness of the new equipment? Perhaps it was a little of both, combined with the manufacturers' not providing the training required for the customers to achieve optimal value through improvement in process. Additionally, the opportunity for "seamless integration" of components also left something to be desired. In the article by John Vanden Brink, in this issue of Applied Radiology, he reports that the actual purchases of PACS are much lower than the projected purchases. This may be due to the impact of customers not achieving results that met their expectations.

Here we are at the start of the next ten years of PACS and related technologies. In this day and age, many of the technical challenges have been solved. Seamless component integration is much closer to a reality and, in many areas, it has been achieved. However, some technical challenges are still present. As John Vanden Brink points out, "moving images at 40 Mbytes/procedure at millisecond speeds, integrating non-standard information systems and replacing films with workstations on a cost-effective basis have been formidable challenges to the integration of PACS." An area of major change for the better during the next ten years will be a more thorough knowledge of the customer. Manufacturers need to facilitate change in user behavior in order for their customers to achieve the most value from their products. The many PACS-related courses and programs have contributed to this insight, and there has clearly been a significant increase in the number of radiologists, administrators and other personnel that are attending educational programs.

Signs of success in utilizing PACS cost effectively are beginning to appear. Examples such as improvements in report turnaround time, improved physician access, and faster treatment in emergency room applications have been reported. The study by Dr. Eliot Siegel, at the Baltimore VA, suggests that the greatest cost savings are realized at the hospital or enterprise-wide level rather than in the radiology department itself (see article on page 15). The results achieved were based on a combination of applying both technology and behavior modification to achieve the best value. The "technology/behavior" tie will remain a key ingredient in bringing PACS-related technology to fruition cost effectively.

Dr. Schilling is president of RBS Consulting Group in Los Altos Hills, CA. He is also a member of the editorial advisory board of this journal.