PACS control debate - radiology or IT - spices SIIM meeting

July 1, 2008

The choices may not be all that stark, but debate persists over who controls PACS-radiology or IT. The question was contested by two able advocates at the Society of Imaging Informatics in Medicine meeting.

The choices may not be all that stark, but debate persists over who controls PACS-radiology or IT. The question was contested by two able advocates at the Society of Imaging Informatics in Medicine meeting.

Much of what is considered PACS today is already under control of the IT department, said Dr. Paul Chang of the University of Chicago. He argued that long-term trends such as the move toward centralized data storage, growing importance of ima¬ges to the electronic health record, and need for tighter integration of all data sources speak for an enterprise approach to the management of medical data, including imaging.

Dr. David Channin of Northwestern University countered that radiology should be wary of attempts to coopt PACS and technology innovations. Radiology can lead the technology wave, as it traditionally has, and help other departments.

But, if it is to continue to innovate, it must retain control of its own destiny and, especially, its own budget.

Chang, who holds positions in both informatics and radiology at Chicago, argued from the enterprise perspective, essentially asserting that the world is a better place when imaging is part of a larger community where all specialties share resources and information in a coordinated fashion.

Already, many structural components of PACS, such as networks, are controlled by IT. In particular, a shared archive can be very cost-effective, and much of what we now define as PACS is going to live in that archive, he said.

Chang has found that much of what his informatics team is involved in is the management of images throughout the enterprise by other producers and consumers of images. Workflow is complex, and many in the enterprise want access to not just images but other information from other domains as well. This access is easier to provide from an overriding entity such as a properly designed and responsive IT structure.

"IT should be at the table because radiology should be at the table," Chang said. "What works in radiology is going to work in pathology, too, with some minor variations. It would be foolish to waste that expertise."

To punctuate his points, Channin ascended the dais wearing a green fatigue cap and dark glasses, sporting a big cigar, and speaking with Spanish-accented English.

"We will tell you how many potatoes to plant and grow," Channin said. "We have excellent healthcare in Cuba, and everyone drives a 1952 Chevy."

He went on to argue that if radiology is under the control of a central authority, it will have to compete with everyone else for technology improvements or upgrades.

"Radiology IT has to be in radiology just as PACS must be in radiology," Channin said. "The bottom line is always the bottom line. If your 3D workstation or your PACS upgrade is in the same pool, or should I say cesspool, of capital allocations, you're going to compete for money for innovations with the next laser doodad in the OR."

Radiology is a cash cow for hospitals that helps fund other, money-losing, services, according to Channin. That's all right by him, however, because "we are a generous and kind people." But for radiology to continue to generate good returns, it needs to define its own standards (such as DICOM and IHE) and innovate in its own way and at its own pace.

"If radiology doesn't have control, it must coordinate with other systems," Channin said. "They may say to you, as they have to me, that you cannot upgrade your radiology xyz until next August when that will synchronize with another system."

Budgetary authority was a major flashpoint.

"It's naïve to think if you control your own little sandbox, you can control your own budget. For most of us, it's one bag of money. I want to be at the table and say my need for PACS is more important, and the only way I can do that is if I can demonstrate I am a team player," Chang said.

That's the job of radiology chairs, who can budget appropriately and who should have budgetary authority for their domains, Channin said.

That's the way it used to be, but not how it works now, Chang said. Today, you have to fight for a share of a single pot of money and articulate your needs in terms of the strategic goals of the enterprise, not just of a department. Channin countered that radiology departments that control their own destiny can increase growth in revenues.