As filmless imaging and data storage revolutionize radiology, many European imaging professionals find themselves at a crossroads. PACS represents an opportunity to reduce many costs, but requires a substantial investment of time, personnel, and financial resources. Decisions about whether to go digital must not only meet local requirements but incorporate an awareness of regional, national, even continental efforts to establish networks and data standards.

With this in mind, we invited a PANEL of radiologists, PACS users, and academics to discuss Europe's transition to filmless imaging at both local and international levels.

Radiologists on the PANEL were Dr. Valentin Sinitsyn of the Cardiology Research Center, Moscow; Prof. Dr. Dimiter Tscholakoff of Rudolfstiftung Hospital, Vienna; Dr. Frits Barneveld Binkhuysen of Hospital Eemland, Amersfoort, and Bart ter Haar Romeny, Ph.D., of Eindhoven University of Technology, both in the Netherlands; Dr. Robert Lavayssière of Sarcelles, France; and Dr. Mogens Rahbek of Slagelse, Denmark.

Also on the PANEL were Prof. Heinz Lemke of the Technische Universität Berlin and Thorsten Kruse of the West Zealand County health services administration in Denmark. The PANEL was moderated by Dr. Nicola Strickland, a consultant radiologist at Hammersmith Hospital in London.

Strickland:
What are the main factors driving a move to PACS around the continent?

Ter Haar Romeny:
The well-known fact is that the smoothness of your department will improve. Everybody is now going digital, and PACS opens up more possibilities for data and image manipulation.

Barneveld Binkhuysen:
I agree, but there are other factors. To improve quality, reduce costs, and introduce all the new developments that are possible in patient management, like computer-assisted detection (CAD) and electronic medical records, you need a good, functional PACS, especially for proper workflow management.

Strickland:
Are we talking just about PACS, or are we actually talking about a fully digital hospital? It's becoming almost impossible to separate PACS from the entire workflow, including the electronic patient record. I think we take HIS (hospital information systems) and RIS (radiology information systems) for granted now.

Kruse:
A PACS itself is worth almost nothing. It's the pumping device of a RIS. The RIS comes first because it is the brain of the system, and the PACS is merely the heart pumping pictures around.

At any given time at a Scandinavian hospital, 15% of your images are unavailable. The good thing about PACS is that they can be simultaneous at various locations. From a practical point of view, that could be a driving force for moving toward PACS. But to move toward PACS without having moved to RIS would be ill-advised.

Barneveld Binkhuysen:
I disagree; I think RIS is not that important. There are a couple of functions, of course, like scheduling and maybe billing or patient registration, but that can be done by workflow management. Workflow management is the key in your imaging system, also for your PACS. That defines your functionality. Your RIS is only a small part. I think RIS will fade away in the near future.

Strickland:
That's quite a radical opinion. Do we have any disagreement?

Tscholakoff:
It depends on how you define RIS. RIS is very important if it is workflow software. When you have a smooth workflow and an appropriate RIS, your PACS will function very well. HIS and RIS have to work together to meet the radiology department's needs. There must be a very good connection to the HIS, but you must be able to trigger your rescue maneuver when the HIS goes down.

Lavayssière:
I'm a radiologist in private practice, and as an end user I'm always impressed by the theoreticians because they are full of ideas about where the RIS should be and where the HIS should be. But when you have to use the system, in fact you are only adding drawbacks. What we want is something that works, and as far as I know, most PACS are not working properly.

Strickland:
What's your evidence for that?

Lavayssière:
Well, I don't mean the Hammersmith, of course! There's a famous example in Paris: L'Hôpital Georges Pompidou. In my institution, we started our PACS in 1995. We have multiple vendors, and it is still not working.

Strickland:
I'm sure everyone around this table has had problems with computer systems, be they PACS or not. It also depends whether by working properly, you mean a completely filmless environment.

Let's come back to whether we feel there are other factors driving a move to PACS around the continent. What are the most significant barriers for hospitals that have not converted?

Ter Haar Romeny:
A very important factor is the IT-related staffing in the radiology department. If I look at significant PACS efforts in Europe, local people really do the job. They know the radiologists. They know the questions. They know what kinds of pitfalls computer systems have.

Most hospitals, however, look to the companies: Can you sell a turnkey system and install it? That doesn't solve the entire equation. If a hospital doesn't have those people, you can't find them, because they're just unavailable in the market. There are few qualified people, and that's a major bottleneck right now.

Lemke:
In my opinion, the greatest barrier to PACS is the initial cost to move into the filmless environment. To move into PACS, even a medium-sized hospital probably has to put on the table ¤1 million or ¤2 million. This money is not just available anywhere.

In the PACS undertaking in Saxony in Germany, seven major hospitals are being converted. They never would have done it if the state hadn't provided the financial backing. Now 90 more hospitals are queuing up to do it.

The other aspect is certainly complexity, I agree. But most people don't know anything about complexity, so they underestimate the problems in moving into PACS. If they looked into it clearly, they would be frightened not only by investment costs but also by complexity.

Kruse:
And running costs.

Lemke:
Yes. PACS and RIS together are one of the most complex information systems we have--certainly within healthcare, and within computer science in general. In computer science, we are not able to model and simulate these very complex systems. That's the reason they are full of faults. Complexity is a problem: in specifying, selecting, implementing, maintaining, and updating the systems.

Kruse:
One barrier is a mental barrier. You need these people with proper experience to go ahead and try it in spite of, perhaps, the financial situation. And then you have to keep them on the job. One of the barriers is that once you have good people, they get picked up by industry.

The other barrier is the running cost. If you take standard radiology equipment, the running cost is about 10% a year, except for maintenance, etc. But if you're going into the digital world, you double that. If you told people up front, "If you're going to run a digital department, you have to have running costs of about 20% for your investment," that would cool people off--and it should.

Apart from getting rid of the film machinery and all the chemicals, the advantages are scattered on all the user ends. It's hard for a hospital's financial department to say, "I want one-quarter of that person and one-fifth of that department, and 10% of that department." It's very difficult to materialize in financial terms what to get out of the PACS/RIS.

Barneveld Binkhuysen:
One of the problems is that the decision-makers in hospitals are confronted with conflicting information. On the one hand, they hear success stories. When doctors in the hospital want to have PACS, they mention only the fine results elsewhere. But on the other hand, decision-makers also hear, "Well, it's not functioning that well. It's not quite ready and you can't go back, and it will cost more money than you expected."

Ter Haar Romeny:
PACS is a vital system that you can't be without for long. A third of all the equipment investment in hospitals is related to imaging. That's a lot. I sometimes compare it with our perceptual senses: Vision is by far the most important. You can't go without vision for half a day. It's the same in hospitals; the PACS should always be working, and that's not the case. That's what people are afraid of.

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