Breaking up with PACS vendor can be hard to do

PACS has been around long enough that some vendor-customer relationships are beginning to fray. When dissatisfaction reaches critical mass, divorce is indicated.

Every unhappy PACS family is unhappy in its own way. Some groups may be displeased with the PACS itself - with missing features or substandard vendor service and support.

"Users may not like the graphical user interface, or the radiologists may be more used to working on a different system and feel less productive on the present system," said Dr. Greg Mogel, an assistant professor of radiology and biomedical engineering and medical director of imaging at University of Southern California University Hospital.

Sometimes the issues are more objective and therefore insurmountable, as with constant compatibility problems that arise when new subsystems are added.

USC University Hospital is one of several facilities recently to dissolve the current PACS relationship and engage another PACS vendor.

Shands Jacksonville Medical Center, an academic medical center affiliated with the University of Florida, made the switch after operational uptime and reliability issues surfaced with its old PACS.

"Our PACS was unable to keep up with the growth of our department," said Kevin Cuda, administrative director of radiology.

Once SJMC began separation procedures, the center was on the air with the new system in under seven weeks. Dissatisfied radiologists led the charge, championing the idea and embracing a new PACS.

Cuda recommends first thoroughly researching products on the market with an understanding of what the new PACS must deliver.

"Then, whether it's an enterprise or departmental solution, radiology directors should engage physician and hospital senior management to get buy-in," he said.

Depending on which format has been used to store images, complex data migration issues can emerge during a PACS transition. Where data were stored in a proprietary format, migrating the data to a new PACS requires that the original vendor be involved. Where data were stored in DICOM, or can be accessed through a DICOM Query/Retrieve, migration will be easier but may still require many months, depending on archive size.

Travis Air Force Base in Fairfield, CA, budgeted about six months for data migration for its 2004 switch.

"The biggest problem is migration of data," said SMSgt Brian Fagan, an Air Force radiology technician who worked on the project.

It's not only the images that you need to worry about, Fagan said. You also have to worry about the orders that go with them.

Since most vendors have a unique way in which orders generated from the RIS are stored in the database, when a new PACS is installed either the old database must be converted to the new format, or the old data must be regenerated in the new database.

"That means you'd have to go back and regenerate the original orders out of the RIS to migrate all the data over so that you end up with a clean database on the back end," Fagan said.

What Fagan did was have the new vendor create ad hoc reports out of the RIS.

"We made the new PACS think that it was getting a new HL7 message on the order, then it gets saved into the database," he said. "Once it's saved, we can migrate the images across."

One way to avoid migration issues in the future is to tailor the current contract to anticipate possible migration.

"Contracts should always specify that imaging data can be retrieved to any third-party DICOM-compatible application using standard DICOM services," said Henri "Rik" Primo, director of marketing and strategic relationships for Siemens Medical Solutions.

SJMC minimized most of its data migration issues by using its third-party disaster recovery site as a broker. Essentially, SJMC archive data were first off-loaded to the backup/disaster recovery servers, then uploaded onto the new PACS.

"Once we got the new PACs, we migrated everything from the disaster site to the new archive," said Charles Swenson, SJMC's PACS coordinator. "This way, we avoided any direct PACS-to-PACS data migration issues."

In any case, making the decision to switch PACS is clearly not trivial. Even when transition goes smoothly, it's a lengthy process. At USC, it took two to three months' lead time to the early 2007 switchover, then a month or two to disengage from the old PACS.

"We're still not entirely disentangled," Mogel said.

Other residual human problems can result from the switch to a new PACS. USC had its old PACS for only about two years, so switching to a new PACS so soon generated not only a training burden but also potential danger of a trust issue surfacing at the radiologist and clinician levels, particularly if many radiologists are ambivalent to the change.

"Radiologists and clinicians will wonder if the information technology guys know what they're doing, so you need to have broad buy-in from radiologists and referring clinicians before you start," Mogel said.

Even then, it can be difficult to please everyone. In some cases, the new PACS may have a different user interface the radiologists don't like, but a great web application that the clinicians love, Mogel said.

Unreasonable user expectations can also be an issue.

"When you switch to a new PACS, users automatically assume that all the undesirable features of the old system will disappear and that any good features will be carried forward to the new system, which we all know is not true because they are different systems from different vendors," said Kevin Wang, technical lead of the USC informatics division.