PACS vendors press single-source integration as way to boost productivity

December 20, 2004

Improved productivity and the promise of fewer errors have lit a fire under manufacturers to integrate PACS with RIS and 3D. The thrust toward integration has been a long time coming. Major vendors of PACS have also offered RIS, but most of these products had been sold overseas, and early penetration into the RIS market in the U.S. was accomplished by best-of-breed companies selling stand-alone IT products.

Improved productivity and the promise of fewer errors have encouraged manufacturers to integrate PACS with RIS and 3D. The move toward integration has been a long time coming. Major vendors of PACS have also offered RIS, but most of these products have been sold overseas, and early penetration into the RIS market in the U.S. was accomplished by best-of-breed companies selling stand-alone IT products.

This change over the last several years has devastated the best-of-breed firms. Most have been either swept from the market or acquired. The few that remain, such as Swearingen Software, are struggling.

"We are the best radiology information system in the marketplace," said company founder Randall Swearingen. "We are plug and play and we can work with anybody. But that has become an extremely hard sell over the last two or three years because of the market hype for a single source."

The RIS products now being introduced by multimodality and major IT vendors are positioned as the engines behind their PACS. Siemens has integrated Novius RIS into its PACS, according to Henri "Rik" Primo, Siemens' national director of marketing and strategic relationships.

"The product of the radiology department is not just the image but the report," he said. "By integrating RIS and PACS, our users have the capability to shorten the time between exam and report."

Siemens, like all large IT vendors, advocates a single-source purchase when shopping for IT components. Primo noted that Siemens' RIS/PACS is part of the much larger Soarian clinical IT product line, which stretches across multiple hospital departments. It therefore makes sense to stay within the family when expanding outward, the company claims.

"The total gain in productivity comes only when the system is integrated," Primo said. "If you have systems from multiple vendors, you have to be very careful about how you integrate them."

Although many RIS/PACS are scalable, their benefits have accrued mostly to large institutions, as these systems rely heavily on high-cost components beyond the budgetary reach of midsize and smaller operations. But vendors big and small are coming to recognize this fact, as well as the sales potential this largely evergreen turf represents.

Working with data storage provider EMC, GE Healthcare has developed Centricity SE, a PACS tailored specifically to community hospitals and imaging centers. This PC-oriented PACS has the same functionality as GE's enterprise edition PACS, but on a lesser scale. Its centerpiece is EMC's new low-cost Clariion AX100 networked storage system. Outfitted with all the bells and whistles, Centricity SE sells for about $1 million.

"With this, smaller hospitals can have the same advanced capabilities as Brigham and Women's, Northwestern, any of the other major sites that use Centricity," said Peter McClennen, GE's global general manager of imaging and information systems.

Although scaled-back systems punctuated vendor offerings, the enterprise systems garnered most of the attention on the RSNA exhibit floor. At the top of the hierarchy was the electronic patient record, as expressed by mega-IT vendors such as McKesson.

McKesson jumped into PACS several years ago with its acquisition of ALI Technologies, integrating the small company's PACS platform as an extension of its homegrown IT systems. McKesson's Horizon Radiology now forms the cornerstone of its image management offerings. The Web-based RIS/PACS includes image management, navigation, information management, workflow automation, and digitization of the patient record. The system channels images and data to the radiologist where and when they are needed, according to Joseph D. Biegel, vice president of product management in the McKesson Medical Imaging Group.

"We literally follow the docs' progress through the study," he said. "Using some algorithms we have developed, we load data around what they are viewing. Even if they take a nonlinear jump to another part of the study, we are ready and have loaded the data. This way we spend the compute time where the doc is."

Three new technologies expedite this process. Adaptive image loading optimizes image display and navigation. Virtual image management supports the visualization of data from multislice CT and other high data volume modalities. Clinical series mapping renames exams and images from different modalities and equipment brands as necessary to ensure that the data can be found quickly.

Intelligent processing has the greatest impact in the examination of high-volume imaging studies, where it enhances response time and speeds productivity. But it also has an effect when users are working with smaller data sets over a narrower data conduit, such as the Web.

"It allows us to allocate resources, based on bandwidth as well as the computing platform, to maximize performance without using compression schemes, which can potentially affect the integrity of the stored data," Biegel said.

McKesson deploys a wide range of specialty-driven ITs. Some sites complement their RIS/PACS with a cardiology-specific information system. Others use McKesson's Horizon Physician Portal to access information from across the healthcare enterprise.

"The portal really knits together the entire information system addressing the patient," Biegel said.

PACS data are routinely accessed through this portal and through other, less expansive McKesson systems. This practice will grow more common, Biegel said, and McKesson is intent on promoting it.

"Our goal is to be the most connectable diagnostic imaging PACS company in the business," he said. "We do that today by using open standards when they are there, and when they are not, we solve clinical problems with advanced IT methods."

But RIS/PACS and their medical IT cousins have varying degrees of integratability, according to Swearingen, who contends that the beauty of many sprawling IT systems is only skin-deep.

"When you look at single-source systems and you peel back the first layer, you find individual modules just sitting there," he said. "They are interfaced, not integrated. But what manufacturers are touting is integration."

Whether the components are integrated or simply interfaced may be more of a semantic than a practical issue, as the linkages, regardless of type, provide the means for expanding beyond radiology PACS into other "ologies." This connectability also supports the addition of advanced processing tools to PACS. Including such tools, particularly 3D, has become critically important with the growing acceptance of 16-slice CT and the prospect of 64-slice scanners.

The acquisition of AccuImage by Merge eFilm days before the RSNA meeting suggests one route PACS firms might take to bolster 3D capabilities (see accompanying story). The converse is also possible, as Cedara Software demonstrated. Well known as an OEM supplier of workstations and software toolkits, Cedara ventured into PACS with the October acquisition of eMed (SCAN 10/27/04).

Another route is to ally with companies such as TeraRecon, whose 3D server can be tailored to work in concert with PACS. Agfa, Amicas, Sectra, Delft Diagnostic Imaging, and Intelerad Medical Systems took advantage of TeraRecon's flexibility, integrating that firm's AquariusNET 1.5 with their own PACS on the RSNA exhibit floor to achieve high-performance 3D.

"The ability to do advanced image processing over an enterprise is more powerful than doing it singly in a dedicated place, and the reason we can do this is that we have hardware dedicated to the task of 3D volume rendering, image acceleration, and networking," said Steve Sandy, vice president of marketing at TeraRecon.

Although Amicas offers AquariusNET 1.5 as an option on its PACS, it also gives customers the choice of Voxar's 3D. There are advantages to both.

"TeraRecon is more expensive because it is server-based, whereas Voxar is plug-and-play software," said Brad Levin, Amicas director of strategic marketing. "But TeraRecon has features that Voxar doesn't have."

Many vendors leverage partnerships to expand the capabilities of their PACS. They may develop interfaces for voice recognition products from Dictaphone and TalkTechnology or for document management from PACSGear. When it comes to postprocessing, however, some companies prefer homegrown solutions.

ViewForum, Philips' high-end postprocessing technology developed initially for workstations, has been integrated into the company's EasyAccess PACS. A new development, Intelligent Volume Inspection, supports protocol-driven 3D viewing of large data sets.

"Volume Inspection addresses clinical applications. It does coronary measurements, virtual colonoscopy," said Sybo Dijkstra, marketing director for Philips Medical IT. "So it is more than just making a nice volume picture. It aids the decision-making process of the radiologist."

In the end, 3D is just one of an increasing number of postprocessing capabilities being put at the disposal of PACS users. How these tools are used, rather than their availability, determines the effectiveness of the PACS.

"Postprocessing is essential, but it has to fit within the whole workflow," Primo said. "The biggest thing, the one purpose, of PACS is to shorten the time between exam and report."